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.