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.
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