Endobronchial Brachytherapy

POLICY NUMBER

L.8.03.404

DESCRIPTION

Endobronchial brachytherapy is the delivery of radiotherapy directly to endobronchial lesions, either intraluminally or interstitially, using permanently implanted radioactive seeds or a temporary afterloading implant. The technique permits targeted radiation while minimizing exposure to surrounding radiosensitive structures, such as normal lung, heart, and spinal cord.

Endobronchial Lesions

BrachytherapyEndobronchial brachytherapy has been primarily investigated as a palliative treatment of obstructing primary or metastatic tumors, particularly in non-small-cell lung cancer. Endobronchial brachytherapy has also been used as a tool in the curative treatment for some primary bronchial and tracheal tumors. Two to four fractions delivered weekly is a typical schedule. Median overall survival of patients with obstructing endobronchial tumors is typically less than 9 months.

In the outpatient setting, the patient receives local anesthesia and monitored sedation. A flexible bronchoscope is passed transnasally; a separate port on the bronchoscope allows passage of the afterloading catheter to the target lesion. Once the catheter is placed, the radioisotope can be administered by the high-dose rate radiotherapy afterloading machine. Patients with potential airway compromise due to bleeding may require treatment with a rigid bronchoscope, which requires general anesthesia and frequently an overnight stay.

Other TreatmentsEndobronchial brachytherapy is an approach to the local treatment of endobronchial lesions. Other technologies include electrocoagulation, cryosurgery, laser resection, endosurgery, and endobronchial stent placement. In some instances, the therapies may be used together, such as using laser therapy for initial debulking followed by brachytherapy.

Several bronchoscopes (FDA product code: EOQ) and remote-controlled afterload/radionuclide applicator systems (product code: JAQ) have been cleared for marketing by the U.S. Food and Drug Administration through the 510(k) process. Examples of both include the Video Sciences BRS-5000 Video Bronchoscopy with EndoSheath® System (Vision-Sciences) and microSelectron® (Nucletron), respectively.

POLICY

Endobronchial brachytherapy may be considered medically necessary in the following clinical situations:

• In individuals with primary endobronchial tumors who are not otherwise candidates for surgical resection or external-beam radiotherapy due to comorbidities or location of the tumor.

• As a palliative therapy for airway obstruction or severe hemoptysis in individuals with primary, metastatic, or recurrent endobronchial tumors.

Other applications of endobronchial brachytherapy are investigational including, but not limited to, its use as a radiation "boost" to curative external-beam radiotherapy, as a treatment for asymptomatic recurrences of non-small-cell lung cancer, or in the treatment of hyperplastic granulation tissue.

POLICY EXCEPTIONS

None

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

A.  consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and

B.  appropriate with regard to standards of good medical practice; and

C.  not solely for the convenience of the Member, his or her Provider; and

D.  the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.

POLICY HISTORY

5/1999: Approved by Medical Policy Advisory Committee (MPAC).

2/13/2002: Investigational definition added, coding information moved from Policy Guidelines section to the Code Reference section and revised.

4/24/2002: Type of Service and Place of Service deleted, Code Reference section updated, CPT code 77776-7778, 77799 added, ICD-9 procedure code 33.23 added, HCPCS Q3001 added.

4/19/2004: Policy reviewed, Sources updated.

8/23/2005: Code Reference section updated, “Previously the bronchoscopy component of endobronchial brachytherapy was probably coded by CPT code 31641 (bronchoscopy with destruction of tumor) or by using CPT codes 77761-63 with a modifier -62 to indicate the participation of a surgeon/pulmonologist in addition to the radiation oncologist.” deleted, CPT code 31643, 77790 description revised, CPT code 77326-77328, 77761-77763 description revised and listed separately, CPT code 77776-77778, 77781-77784 listed separately, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 162.2-162.9 listed separately, ICD-9 diagnosis code 231.2 deleted.

8/18/2008: Policy reviewed, no changes.

12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions.

03/22/2010: Policy description updated. Policy statement changed to indicate that use as palliative treatment for severe hemoptysis and in recurrent tumors may be considered medically necessary. Policy statement updated to state that use as treatment for asymptomatic recurrent disease or to treat hyperplastic granulation tissue is considered investigational. Deleted outdated references from the Sources section. Revised the description of CPT code 31643.

04/20/2011: Policy description and statement unchanged. Removed deleted CPT codes 77781, 77782, 77783, 77784 from the Code Reference section.  

03/27/2012: Policy reviewed; no changes.

04/17/2013: Policy reviewed; no changes.

03/18/2014: Policy reviewed; no changes.

12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, and 77318.

03/12/2015: Policy reviewed; description updated. Medically necessary policy statement updated to change "radiation therapy" to "radiotherapy." Investigational policy statement updated to change "external beam radiotherapy" to "curative external beam radiotherapy."

08/28/2015: Code Reference section updated for ICD-10.

12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to remove deleted CPT codes 77326, 77327, and 77328. Added new 2016 CPT codes 77770, 77771, and 77772. Code description for CPT code 77778 revised with an effective date of 01/01/2016.

05/27/2016: Policy number A.8.03.11 added.

01/19/2017: Policy description and statement unchanged. Code Reference section updated to remove deleted CPT codes 77776, 77777, 77785, 77786, and 77787. Updated description for CPT code 77778.

01/23/2018: Policy description updated. Policy statements unchanged.

08/15/2018: Policy description updated. Policy statements unchanged.

08/22/2019: Policy reviewed; no changes.

09/03/2020: Policy reviewed; no changes.

12/06/2021: Policy description updated regarding devices. Policy statements unchanged. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity."

08/25/2022: Policy reviewed. Policy statements updated to change "patients" to "individuals."

08/15/2023: Policy reviewed; no changes.

01/31/2025: Policy updated to change the medical policy number from "A.8.03.11" to "L.8.03.404." Policy reviewed. Policy statements unchanged.

SOURCE(S)

Blue Cross Blue Shield Association policy # 8.03.11

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy. 

The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.  

Endobronchial brachytherapy is a multi-step procedure requiring a series of radiation oncology CPT codes for radiation treatment planning, radiation physics, treatment delivery and clinical treatment management. In contrast to other types of radiation therapy, endobronchial brachytherapy requires the services of a radiation oncologist and a pulmonologist or other physician to perform the bronchoscopy and insert the catheter. In 1999 a new CPT code, 31643, was introduced that specifically identified the catheter placement. 

Covered Codes

CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.