Mid-Arm Circumference and Triceps Skin

CIGNA HEALTHCARE COVERAGE POSITION
Subject Brachytherapy of the Prostate
Table of Contents
Coverage Position............................................... 1
General Background ........................................... 2
Coding/Billing Information ................................... 7
References .......................................................... 9
Revised Date ........................... 10/15/2006
Original Effective Date ........... 10/15/2005
Coverage Position Number ............. 0419
Hyperlink to Related Coverage Positions
Cryoablation for Prostate Cancer
Gene-Based Testing for Prostate Cancer
Screening, Detection and Disease
Monitoring
Inpatient Stays for Radiation Therapy
Intensity-Modulated Radiation Therapy
(IMRT)
Intraoperative Radiation Therapy
Laparoscopic Radical Prostatectomy
Neutron Beam Therapy
Prostate Saturation Biopsy
Prostate-Specific Antigen (PSA) Screening
for Prostate Cancer
Proton Beam Therapy for Prostate Cancer
Stereotactic Radiosurgery
Transrectal Ultrasound (TRUS)
Tumor Markers for Diagnosis and
Management of Cancer
INSTRUCTIONS FOR USE
Coverage Positions are intended to supplement certain standard CIGNA HealthCare benefit plans. Please note, the terms of a
participant’s particular benefit plan document [Group Service Agreement (GSA), Evidence of Coverage, Certificate of Coverage,
Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which
these Coverage Positions are based. For example, a participant’s benefit plan document may contain a specific exclusion related to
a topic addressed in a Coverage Position. In the event of a conflict, a participant’s benefit plan document always supercedes the
information in the Coverage Positions. In the absence of a controlling federal or state coverage mandate, benefits are ultimately
determined by the terms of the applicable benefit plan document. Coverage determinations in each specific instance require
consideration of 1) the terms of the applicable group benefit plan document in effect on the date of service; 2) any applicable
laws/regulations; 3) any relevant collateral source materials including Coverage Positions and; 4) the specific facts of the particular
situation. Coverage Positions relate exclusively to the administration of health benefit plans. Coverage Positions are not
recommendations for treatment and should never be used as treatment guidelines. ©2006 CIGNA Health Corporation
Coverage Position
CIGNA HealthCare covers brachytherapy for the treatment of prostate cancer as medically
necessary when the cancer is clinically confined to the prostate and when any ONE of the
following criteria is met:
•
•
•
The administration method will be low-dose treatment, using permanently implanted seeds as
monotherapy, for patients with low-risk cancers.
The therapy is administered in conjunction with external beam radiation and/or neoadjuvant
androgen ablation for patients with intermediate-risk cancers.
The therapy is used to deliver a high-dose treatment using a temporary implant technique
followed by external beam radiation and androgen ablation for patients with high-risk cancers.
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Coverage Position Number: 0419
CIGNA HealthCare does not cover brachytherapy for palliative treatment of the prostate because it
is considered experimental, investigational or unproven.
General Background
Prostate cancer is the most common cancer in males in the United States. It is anticipated that
approximately 234,460 men in the U.S. will be diagnosed with prostate cancer in 2006. When this cancer
is caught in its early stages, while many tumors are low-grade and slow-growing, survival rates are
excellent, and cure rates can be as high as 98% in some cases. Some evidence has suggested that
heredity may play a role in the development of prostate cancer. Men with a family history are at higher
risk of developing this disease. Having one family member with prostate cancer doubles a man’s own risk,
and having three family members poses an 11-fold risk for this disease (National Cancer Institute [NCI],
2006).
Current screening protocols for the early detection of prostate cancer include the monitoring of prostate
specific antigen (PSA) serum levels and digital rectal examinations. PSA levels can rise as a result of
prostate cancer or may become increased as a result of benign conditions such as prostatic hyperplasia
(BPH), acute prostatitis, or following prostate biopsy. A PSA level of 4.0 nanograms/milliliter (ng/mL) or
less is considered normal; however, 15% of men with this “normal” PSA will have prostate cancer, and
2% will have high-grade cancer (National Comprehensive Cancer Network [NCCN], 2005).
When prostate cancer is suspected, a transrectal, ultrasound-guided prostate biopsy is performed to
confirm the diagnosis. If the biopsy confirms the presence of cancer, then histological staging and scoring
of the cancer is also obtained. Radiological studies (e.g., bone scan or computerized tomography [CT])
may also be conducted to determine if the cancer has metastasized to other organs. By utilizing this
information (i.e., PSA levels, tumor stage and Gleason scoring) patients can be stratified into categories
associated with different probabilities of achieving a cure (Carver, 2006; NCCN, 2005; Kawashima, 2005).
Tumor (T) Staging and Gleason (G) Scoring: T staging and G scores provide guidance for the
physician, the extended treatment team and the patient in determining the best clinical course of care.
There are two systems that may be used for the staging of prostate cancer, the Jewett system (stages A
through D) and the American Joint Commission on Cancer (AJCC), which includes a tumor (T), node (N)
and metastasis (M) staging (NCI, 2006). During this staging and grading process a tumor is analyzed to
determine how well or poorly its cells are organized and, as a result of this cellular structure, the tumor’s
probability of metastasizing to other sites. By utilizing this information, it may be determined that
extensive radiation therapy is needed, a modified or radical surgery and/or adjuvant androgen ablation
therapy is needed to achieve the best treatment outcome (NCCN, 2005).
A (T) staging of:
• T1-a, b, or c to T2-a, b, or c indicates that the tumor is confined to the prostate
• T 3 or 4 indicates that the cancer has spread beyond the prostate
As part of the grading process, it will also be determined if the lymph nodes are involved or if the cancer
has spread to other sites (e.g., the bones). This grading is referred to as a node (N) score:
• N 0 indicates that regional nodes are cancer free
• N1, 2, or 3 indicates that regional nodes are involved
To complete the staging scale of the tumor, it must be determined if the cancer has metastasized (M) to
other organs or body systems.
• M0 indicates no distant metastasis
• M1 indicates distant metastasis
• M1a indicates spread to non-regional lymph node(s)
• M1b indicates spread to the bone(s)
• M1c indicates spread to other site(s) with or without bone disease
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Gleason (G) Scoring: This histopatholgical grading system is considered to be the optimal method of
grading, because it has been clearly shown to be of great prognostic value. The following G indicators
may be assigned to a tumor:
• GX a grade cannot be assessed
• G1 well differentiated (slight anaplasia) (Gleason 2-4)
• G2 moderately differentiated or undifferentiated (marked anaplasia) (Gleason 5-6)
• G3-4 poorly differentiated or undifferentiated (marked anaplasia) (Gleason 7-10)
The Jewett staging system: This system was first described in 1975 and has since been modified to
include:
• Stage A is clinically undetectable tumor confined to the prostate gland and is an incidental finding
at the time of prostate surgery.
o Substage A1: well-differentiated with focal involvement, usually left untreated
o Substage A2: moderately or poorly differentiated or involves multiple foci in the gland
• Stage B is tumor confined to the prostate gland.
o Substage B0: nonpalpable, PSA-detected
o Substage B1: single nodule in one lobe of the prostate
o Substage B2: more extensive involvement of one lobe or involvement of both lobes
• Stage C is tumor clinically localized to the periprostatic area but extending through the prostate’s
capsule; seminal vesicles may be involved.
o Substage C1: clinical extracapsular extension
o Substage C2: extracapsular tumor producing bladder outlet or urethral obstruction
• Stage D is metastatic disease.
o Substage D0: clinically localized disease (prostate only) but persistently elevated
enzymatic serum acid phosphatase titers
o Substage D1: regional lymph nodes only
o Substage D2: distant lymph nodes, metastases to bone or visceral organs
o Substage D3: D2 prosate cancer patients who relapsed after adequate endocrine therapy
(NCI, 2006).
A patient’s age, coexisting medical problems and the aggressiveness of the tumor (i.e., T stage and G
score) may dictate the course of treatment and its timing. Primary treatment options for prostate cancer
include surgery, radiotherapy, and hormonal manipulation. Treatment may occur immediately upon
diagnosis, or a watchful waiting approach may be taken. A radical prostatectomy and external beam
radiation therapy (EBRT) continue to be widely used as definitive therapies for localized cancer. However,
these same therapies carry the risk of post-operative rectal or urinary complications and impotency
(Kawashima, 2005; NCI, 2006).
In an attempt to decrease the side effects of these therapies, alternative methods of delivering radiation
(i.e., brachytherapy) to the prostate have been proposed. Brachytherapy includes the use of radioactive
implants that deliver low-dose (LD) or high-dose (HD) therapy as an adjunct or boost to EBRT. In select
patients, brachytherapy as a monotherapy may eliminate the need for EBRT in the treatment of prostate
cancer.
Brachytherapy
Brachytherapy is one method that may be used to deliver high radiation doses to nearby tumor tissue,
while sparing normal tissues that are located distal to the site of radiation. The goal of this treatment is to
prevent the recurrence of any residual cancer with minimal adverse outcomes. The implantation of
radioactive agents takes specialized training by the surgeon, the radiation oncologist and the imaging
staff. There are several determining factors that impact the treatment course used to deliver radiotherapy:
the location of the tumor; the size and shape of the tumor; the type of tumor, genetic factors and
hormonal receptors of the tumor (American Cancer Society [ACS], 2006; American Society for
Therapeutic Radiology and Oncology [ASTRO], 2006; Carver, 2006; Chue, 2005; NCI, 2006).
When brachytherapy is used for the treatment of prostate cancer, transrectal ultrasonography is used to
guide the placement of steel-encapsulated 125Iodine (125I) or 103 Palladium (103Pd) seeds throughout the
prostate gland. With 125I seeds, the total treatment doses are relatively high (e.g., 145 gray [Gy]);
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however, dose rates are relatively low. The dose rate declines during the actual treatment period as the
iodine within the implanted seed decays (i.e., the half-life of 125I is 59.6 days). Because of these factors, it
is difficult to speculate regarding the predicted biologic effects of permanent prostate implants versus
fractionated EBRT regimens. One drawback of permanent implantation is the potential for underdosing a
portion(s) of the tumor. This can possibly occur if seeds are misplaced during the procedure, or they may
shift after placement. Asymmetric radiation emissions are observed around cylindrical seeds, which may
cause underdosing of some regions. The clinical reports to date suggest that prostate tumors with
favorable prognosis are equally well controlled with interstitial implants and fractionated EBRT. The use of
prophylactic radiation of clinically or pathologically uninvolved pelvic lymph nodes does not appear to
improve overall survival or prostate cancer-specific survival (Chue, 2005; NCI, 2006).
Several specialty societies have published patient selection criteria for use in determining the appropriate
application of brachytherapy. Patient selection is based on a confirmed diagnosis of cancer that is
clinically confined to the prostate and/or surrounding tissues (i.e., stage I, II, and III). The presence of
metastases should be radiologically ruled out and patient co-morbidities may also influence the treatment
regimen (American Brachytherapy Society [ABS], 2005; American Urological Association [AUA] and NCI,
2006; NCCN, 2005; Radiation Society of North America [RSNA], 2005).
Literature Review
Numerous studies have been conducted regarding the usage of brachytherapy; most have been
retrospective, small in size (ranging from 50 to 2000+), and nonrandomized. According to the NCI, a
retrospective review of 999 patients treated with megavoltage irradiation showed cause-specific survival
rates to be significantly different at 10 years by T-stage: T1 (79%), T2 (66%), T3 (55%), and T4 (22%).
Long-term results with radiation therapy are dependent on stage. Patients considered poor medical
candidates for radical prostatectomy can be treated with acceptably low complications if care is given to
the delivery technique (NCI, 2006).
Potters et al. (2005) presented the 12-year bio-chemical freedom from recurrence (BFR) outcomes from
their eight-year (1992-2000) study of 1449 consecutive patients treated for clinically localized prostate
cancer using brachytherapy with EBRT, neoadjunct hormonal therapy or brachytherapy as a primary
source of radiation therapy. Patients with a PSA of 10ng/ml or less, Gleason score of 2-6 and clinical
stage T1 to T2a tumors were considered low risk and treated with brachytherapy alone. Patients with
PSA greater than 10ng/ml, Gleason score 7-10 or clinical stage T2b were considered higher risk and
were treated with a combination of EBRT and brachytherapy. Seeds were placed using an interstitial gun
applicator without fluoroscopy. During the course of this study, prescribed dosing changed, leading to a
decrease in the amount of EBRT that was delivered in order to compensate for the radiation amounts
already administered using the radioactive seeds. Median follow-up was 82 months, with overall and
disease-specific survival at 12 years of 81% and 93%, respectively. The researchers noted that only 20%
of this study group actually received a combined treatment protocol of brachytherapy and EBRT. The
addition of EBRT may mask a poor dosimetric implant, adding additional toxicity and expense. The role of
adjunctive androgen therapy remains controversial. The researchers concluded that these BFR
outcomes: 1) continue to remain acceptable, 2) they continue to identify a direct relationship between
implant quality as measured by a dose volume of 90% (D90), and 3) when PSA doubling time is less than
12 months in men who experience biochemical failure, aggressive salvage therapy may be required.
They also concluded that additional studies are necessary to determine the specific role of hormonal
therapy, and specific clinical data and dose modeling standards need to be determined that will improve
the efficacy of brachytherapy as a standalone radiation modality.
Sathya and colleagues (2005) conducted a randomized, controlled trial to determine if iridium (IM)
implants and EBRT were more effective than the standard application of EBRT in the treatment of locally
advanced prostate cancer. One hundred and four patients were randomly assigned into two groups (i.e.,
group one receiving IM and EBRT and group two receiving EBRT-alone). All patients underwent a pelvic
lymphadenectomy as a staging procedure and if nodes were determined to be positive, they were
excluded from the study. Patients began EBRT approximately three to four weeks after the pelvic
lymphadenectomy. Patients randomly assigned to receive brachytherapy had cannula implantation at the
time of the lymphadenectomy once the nodes were cleared after frozen section results were obtained.
These cannulas were then afterloaded with IM being delivered over a total of 48 hours before removal.
Patients returned in two weeks and EBRT was initiated. Biochemical or clinical failure (BCF) defined as
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PSA failure, clinical failure, or death as a result of prostate cancer, were the primary outcome measures
for this study. The researchers noted that PSA failure was the earliest event noted in 28 patients (12 in
the implant-plus-EBRT group and 16 in the EBRT-alone group). At the end of 24 months, all patients
were required to undergo a post-radiation biopsy; however, only 87 (84%) of the 104 patients complied. In
the implant-plus group, 10 (24%) of 42 patients had positive results, while 23 (51%) of the 45 patients in
the EBRT-alone group had positive biopsies. The clinical pathologist who read these biopsies was
blinded to the treatment protocol of each patient. During the course of this study, 17 patients died: 10 in
the implant and EBRT group, and seven in the EBRT-alone group. At five years, the probability of survival
was 94% in the implant and EBRT group and 92% in the EBRT-only group. With the medial follow-up of
8.2 years, the researchers concluded that there was no difference in survival detected between these
groups. They also concluded that superior results were obtained with the use of combination therapy
versus EBRT-alone, as evidenced by the post-treatment biopsy results. Sathya and colleagues also
determined that additional studies are needed to compare this treatment with 3D-CRT and/or IMRT, in
which dose escalation is possible.
In a Hayes literature review of 2005, which included two randomized studies, several case series and
review articles, the authors concluded that the use of brachytherapy as a treatment with curative intent for
clinically localized prostate cancer was favorable for use in patients with stage T1 or T2, PSA ≤ 10ng/ml,
and a Gleason score of ≤ 6. They also concluded that there is insufficient evidence that supports the use
of brachytherapy as a salvage treatment for recurrence or when primary treatment failure occurs.
Polascik et al. (1998) conducted a retrospective historical comparison of actuarial PSA progression-free
survival after prostatectomy versus brachytherapy as a monotherapy. After seven years he reported a
97.8% survival after prostatectomy versus 79% after brachytherapy. This study suggests that surgery
versus brachytherapy has a better outcome. This study was nonrandomized; a present surgical series
was used for comparison and standard definitions of biochemical control were not used. In studies where
patients were stratified according to risk categories, outcome rates were better in favorable-risk patients
compared with those at intermediate or unfavorable risk. Favorable risk was defined as stage T1 or T2,
pretreatment PSA of less than or equal to 10 ng/ml and Gleason scores of less than or equal to six
(Walsh, 2002; Merrick, 2005).
The NCI and the Radiation Therapy Oncology Group (RTOG) are recruiting patients to participate in a
phase III randomized trial to compare the effectiveness of interstitial brachytherapy with or without
external beam radiation therapy in treating patients who have prostate cancer. This study will involve
1520 patients and accrual is expected to take five years (NCI, 2006).
NCI is also conducting a phase III randomized trial comparing intermittent versus continuous androgen
suppression for patients with PSA progression in the clinical absence of distant metastases following
radiotherapy. This active study involves 1340 patients; however, outcomes are not available at this time
(NCI, 2005).
Professional Societies/Organizations
The American Brachytherapy Society (ABS, 2005): The ABS inclusion criteria for low-dose
brachytherapy:
• Life expectancy greater than five years
• Clinical stage: T1b-T2c and selected T3
• Gleason score 2-10
• PSA: in almost all cases, a PSA less than 50ng/ml
• No pathological evidence of pelvic lymph node involvement
• No distant metastases
Patient selection for monotherapy:
• Clinical stage T1b-T2b and Gleason score ≤ to 6 and PSA ≤ 10ng/ml
• Select higher risk patients
• Salvage of select radiation therapy failures
Patient selection for boost therapy:
• Clinical stage T2c or greater and/or Gleason score ≥ 7 and/or PSA > 10ng/ml
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Inadequate information exists to recommend supplemental XRT based on perineural invasion, percent
positive biopsies and/or MRI-detected extracapsular penetration (Merrick, 2005).
The American Urological Association (AUA), and the National Cancer Institute (NCI) recognize the
use of brachytherapy only for a select group of patients—those with a prostate volume of less than 60 ml
and who have early-stage prostate cancer (i.e., T1 or T2 tumor, a Gleason grade lower than 7, and a PSA
level below 10ng/ml). Poor candidates for brachytherapy include men who have had a transurethral
resection of the prostate (TURP) and patients with advanced cancer, high-grade tumors, or very large
prostate glands. The ABS also includes patients with a life expectancy of five years or less (Nag, 1999;
NCI, 2005).
The National Comprehensive Cancer Network (NCCN, 2005): Prostate Cancer Guidelines suggest the
use of the following in the treatment of prostate cancer:
• EBRT
¾ Three dimensional (3D) conformal or IMRT (intensity modulated radiation therapy)
techniques should be employed.
¾ Doses of 70-75 Gy in 35-41 fractions to the prostate (± seminal vesicles for part of the
therapy) appear to be appropriate for patients with low-risk cancers.
¾ For patients with intermediate- or high-risk disease, doses between 75-80 Gy appear to
provide improved PSA-assessed disease control.
¾ Patients with high-risk cancers are candidates for pelvic lymph node irradiation and the
addition of neoadjuvant ± adjuvant androgen ablation therapy.
¾ If target prostate tumor volume (PTV) margins are reduced, such as for doses above 75 Gy,
extra attention to daily prostate localization, with techniques such as ultrasound implanted
fiducials, or an endorectal balloon, is indicated.
• Brachytherapy
¾ Permanent brachytherapy as monotherapy is indicated for patients with low-risk cancers (i.e.,
T1-T2a and G score 2-6 and PSA less than 10ng/mL).
¾ For intermediate-risk cancers (i.e., T2b-T2c or G score 7 or PSA 10-20 ng/mL) consider
combining brachytherapy with EBRT (40-50 Gy) ± neoadjuvant androgen ablation.
¾ Patients with high-risk cancers (i.e., T3a or G score 8-10 or PSA greater than 20 ng/mL) are
generally considered poor candidates for permanent brachytherapy; however, with the
addition of EBRT and androgen ablation, it may be effective in select patients.
¾ Patients with a large prostate (> 60 grams [gm]), symptoms of bladder outlet obstruction
(IPSS score > 15), or a previous transurethral resection of the prostate (TURP) are not ideal
candidates because of increased risk of urinary morbidity. Neoadjuvant androgen ablation
may be used to shrink the prostate to an acceptable size.
¾ Post-implant dosimetry should be performed to document the quality of the implant.
¾ The recommended prescribed doses for monotherapy are 145 Gy for 125-Iodine and 125 Gy
for 103-Palladium. The corresponding boost dose after 40-50 Gy EBRT is 110 Gy and 100
Gy, respectively.
The National Cancer Institute (NCI, 2005) standard treatment options for patients diagnosed with T1 or
T2A prostate cancer are as follows:
• Stage I (AJCC-T1a, N0, M0, G1 [Gleason score 2-4] or Jewett stage A1):
¾ careful observation without further immediate treatment in selected patients
¾ radical prostatectomy, usually with pelvic lymphadenectomy. Postsurgical radiation therapy
may be appropriate for patients who are found to have capsular penetration or seminal
vesicle invasion or when PSA levels are detectable more than three weeks after surgery.
¾ external beam radiation therapy
¾ interstitial implantation of radioisotopes (i.e., 125-I, palladium, iridium) using a transperineal
technique with ultrasound or CT guidance. Retropubic freehand implantation with 125-I has
been associated with an increased local failure and complication rate. This technique is rarely
used at this time.
• Stage II (AJCC-T1a-c, N0, any G or Jewett stage A2 or B1 or B2):
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radical prostatectomy, usually with pelvic lymphadenectomy. Postsurgical radiation therapy
may be appropriate for patients who are found to have capsular penetration or seminal
vesicle invasion or when PSA levels are detectable more than three weeks after surgery.
¾ careful observation
¾ external-beam radiation therapy
¾ external beam radiation therapy plus androgen-suppression therapy
¾ interstitial implantation of radioisotopes (i.e., 125-I, palladium, iridium) using a transperineal
technique with ultrasound or CT guidance. Retropubic freehand implantation with 125-I has
been associated with an increased local failure and complication rate. This technique is rarely
done at this time.
Stage II (AJCC-T2, N0 any G or Jewett stage B1 or B2):
¾ radical prostatectomy, usually with pelvic lymphadenectomy. Postsurgical radiation therapy
may be appropriate for patients who are found to have capsular penetration or seminal
vesicle invasion or when PSA levels are detectable more than three weeks after surgery.
¾ external-beam radiation therapy
¾ careful observation
¾ interstitial implantation of radioisotopes (i.e., 125-I, palladium, iridium) using a transperineal
technique with ultrasound or CT guidance. Retropubic freehand implantation with 125-I has
been associated with an increased local failure and complication rate. This technique is rarely
done at this time.
Stage III:
¾ external beam radiation therapy
¾ external beam radiation therapy plus hormonal therapy
¾ hormonal manipulations (i.e., orchiectomy or luteinizing hormone-releasing hormone [LHRH]
agonist)
¾ radical prostatectomy, usually with pelvic lymphadenectomy. Postsurgical radiation therapy
may be appropriate for patients who are found to have capsular penetration or seminal
vesicle invasion or when PSA levels are detectable more than three weeks after surgery.
¾ careful observation
Stage IV:
¾ hormonal manipulation (e.g., orchiectomy, LHRH agonists, leuprolide plus flutamide, or
estrogens)
¾ external beam radiation
¾ palliative radiation therapy
¾ palliative surgery (i.e., TURP)
¾ careful observation (in selected patients)
¾
•
•
•
Radiation Society of North America (RSNA, 2005): The RSNA reports that the long-term results that
are available for up to 10-12 years at some institutions show that ultra-sound guided radioactive
implantation by very experienced physicians is highly effective in controlling prostate cancer and has
essentially the same result as surgery or EBRT for appropriately selected low-risk prostate cancer
patients. High-dose brachytherapy (HDR) was developed to supplement EBRT for patients with high-risk
prostate cancer and has been proven to be effective. Use of HDR as a sole radiation treatment for lowrisk patients is still in the developmental stages.
Summary
Brachytherapy in the treatment of prostate cancer has been determined to be safe and efficacious when
delivered conservatively; implanted using ultrasound or computerized tomography guidance; and
administered when the cancer is confined to the prostate. Studies are underway that will determine if lowdose versus high-dose therapy will be as effective, while reducing the potential side effects of radiation
treatment.
Brachytherapy is not generally used as a palliative treatment in patients with advanced cancer, highgrade tumors, or in patients with a life-expectancy of five years or less.
Coding/Billing Information
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Coverage Position Number: 0419
Note: This list of codes may not be all-inclusive.
Covered when medically necessary:
CPT®*
Codes
55859
76873
77263
77280
77285
77290
77295
77300
77326
77327
77328
77336
77370
77470
77761
77762
77763
77776
77777
77778
77781
77782
77783
77784
77789
77790
HCPCS
Codes
C1715
Description
Transperineal placement of needles or catheters into prostate for interstitial
radioelement application, with or without cystoscopy
Ultrasound, transrectal; prostate volume study for brachytherapy treatment
planning (separate procedure)
Therapeutic radiology treatment planning; complex
Therapeutic radiology simulation-aided field setting; simple
Therapeutic radiology simulation-aided field setting; intermediate
Therapeutic radiology simulation-aided field setting; complex
Therapeutic radiology simulation-aided field setting; three-dimensional
Basic radiation dosimetry calculation, central axis depth dose calculation, TDF,
NSD, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of
non-ionizing radiation surface and depth dose, as required during course of
treatment, only when prescribed by the treating physician
Brachytherapy isodose plan; simple (calculation made from single plane, one to
four sources/ribbon application, remote afterloading brachytherapy, 1 to 8
sources)
Brachytherapy isodose plan; intermediate (multiplane dosage calculations,
application involving 5 to 10 sources/ribbons, remote afterloading brachytherapy,
9 to 12 sources)
Brachytherapy isodose plan; complex (multiplane isodose plan, volume implant
calculations, over 10 sources/ribbons used, special spatial reconstruction,
remote afterloading brachytherapy, over 12 sources)
Continuing medical physics consultation, including assessment of treatment
parameters, quality assurance of dose delivery, and review of patient treatment
documentation in support of the radiation oncologist, reported per week of
therapy
Special medical radiation physics consultation
Special treatment procedure (e.g., total body irradiation, hemibody radiation, per
oral, endocavity or intraoperative cone irradiation
Intracavitary radiation source application; simple
Intracavitary radiation source application; intermediate
Intracavitary radiation source application; complex
Interstitial radiation source application; simple
Interstitial radiation source application; intermediate
Interstitial radiation source application; complex
Remote afterloading high intensity brachytherapy; 1-4 source positions or
catheters
Remote afterloading high intensity brachytherapy; 5-8 source positions or
catheters
Remote afterloading high intensity brachytherapy; 9-12 source positions or
catheters
Remote afterloading high intensity brachytherapy; over 12 source positions or
catheters
Surface application of radiation source
Supervision, handling, loading of radiation source
Description
Brachytherapy needle
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C1716
C1717
C1718
C1719
C1720
C1728
C2616
C2633
C2634
C2635
C2636
C2637
C9725
ICD-9-CM
Diagnosis
Codes
185
233.4
Brachytherapy source, gold 198
Brachytherapy seed, high dose rate iridium 192
Brachytherapy source, iodine 125
Brachytherapy source, non-high dose rate iridium 192
Brachytherapy source, palladium 103
Catheter, brachytherapy seed administration
Brachytherapy source, yttrium-90, per source
Brachytherapy source, cesium-131, per source
Brachytherapy source, high-activity, Iodine-125, greater than 1.01 mCi (NIST),
per source
Brachytherapy source, high-activity, Paladium-103, greater than 2.2 mCi (NIST),
per source
Brachytherapy linear source, paladium 103, per 1 mm
Brachytherapy source, ytterbium-169, per source
Placement of endorectal intracavitary applicator for high intensity brachytherapy
Description
Malignant neoplasm of prostate
Carcinoma in situ of prostate
*Current Procedural Terminology (CPT®) ©2005 American Medical Association: Chicago, IL.
References
1. American Cancer Society (ACS). How is prostate cancer treated? Updated Jul 2006. Accessed
Aug 2006. Available at URL address:
http://www.cancer.org/docroot/CRI/content/CRI_2_4_4X_How_is_prostate_cancer_treated_36.as
p?sitearea=
2. American Cancer Society (ACS). How is radiation given? Updated Jul 2005. Accessed Aug 2006.
Available at URL address:
http://www.cancer.org/docroot/ETO/content/ETO_1_4X_How_is_radiation_given.asp?
3. American Society for Therapeutic Radiology and Oncology (ASTRO). Radiation therapy for
prostate cancer. Updated 2006. Accessed Aug 2006. Available at URL address:
http://www.astro.org/pdf/Patient%20Information/astroprostatebrochure2.pdf
4. Carver BS, Dalbagni G, Sheinfeld J. (authors). Malignant Tumors of the Urogenital Tract. In:
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