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TRICARE Policy Manual 6010.60-M, April 1, 2015
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 -

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