Radiology
Chapter 5
Section 3.2
Brachytherapy/Radiation
Therapy
Issue Date: March 27, 1991
Copyright: CPT
only © 2006 American Medical Association (or such other date of
publication of CPT).
All Rights Reserved.
Revision:
1.0 CPT
Procedure Codes
19296, 19298, 77326 - 77328,
77750 - 77799, 79440
2.0 Description
2.1 Brachytherapy
is a type of radiation therapy in which the radiation source is
placed within or very close to the body area being treated. Brachytherapy
involves the use of radioactive isotopes as the radiation source,
permanently or temporarily implanted, in the form of wires or seeds,
into or near malignant tumors that are unresectable or recurrent
following previous resection or radiotherapy. Commonly used radioisotopes
include gold (198 Au), iodine (125 I), iridium (192 Ir), californium
(252 Cf), cesium (137 Cs), and palladium (103 Pd).
2.2 Electronic
brachytherapy is an alternative to radioactive brachytherapy. It
can be delivered in one or multiple fractions. By definition, it
is the delivery of brachytherapy (radiation directly on or into the
target) with electronic systems rather than a radionuclide. Because
of the low-energy x-ray source, the electronic brachytherapy use
location is not limited to the shielded therapy suites necessary
for linear accelerators and Iridium-192 High Dose Radiation (HDR)
after-loading brachytherapy. The intended uses of high-dose-rate
electronic brachytherapy are developing and expanding. However,
the long-term safety and efficacy of the high-dose-rate electronic
brachytherapy has not been determined.
3.0 Policy
3.1 Benefits
may be extended for brachytherapy.
3.2 Radioactive chromic phosphate
synoviorthesis in the treatment of hemophilia patients with hemarthrosis
and/or synovitis is covered when the medical record documents that
more conservative therapies have failed. Current Procedural Terminology
(CPT) procedure codes that apply are:
• 79440 (Intra-articular
radionuclide therapy).
• 77750 (Infusion
or instillation of radioelement).
3.3 Other brachytherapy
techniques and devices (including medically necessary related supplies) are
covered under the program only when it has received permission or
approval for marketing by the U.S. Food and Drug Administration
(FDA) and used according to the labeled indication on or after the day
of FDA approval of the device (i.e., the MammoSite Brachytherapy
System).
4.0 Policy
Considerations
4.1 There are no categorical limitations on the
use of brachytherapy, and indications and patient selection will
vary as with any other form of radiotherapy.
4.2 Following
is a list of conditions for which brachytherapy has been used. This
list is not all-inclusive and should not be used as such:
4.2.1 Cervical,
uterine, and prostate cancer.
4.2.2 Brain tumors, alone or combined
with external beam radiation therapy.
4.2.3 Palliative treatment of bronchogenic
carcinoma.
4.2.4 Adjuvant therapy of:
• Breast cancer.
• Renal cell carcinoma.
• Skin cancer.
• Head and neck cancer.
• Choroidal melanoma.
• Pancreatic carcinoma.
• Liver metastases.
• Bile duct carcinoma.
• Vaginal and vulvar
carcinoma.
• Bladder
carcinoma.
• Sacral
chordoma.
• Childhood
and adult sarcomas.
• Esophageal carcinoma.
• Retinoblastoma.
• Rectal carcinoma.
5.0 EXCLUSIONS
Brachytherapy, when administered through a
high-dose-rate electronic brachytherapy system (CPT procedure code
0182T), is unproven.
- END -