Highmark Commercial Medical Policy - Pennsylvania


 
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Medical Policy: R-23-011
Topic: Radiation Therapy for Breast Cancer
Section: Radiation Therapy & Nuclear Medicine
Effective Date: August 1, 2018
Issue Date: July 30, 2018
Last Reviewed: May 2018

Early stage breast cancer is typically treated with mastectomy with or without radiotherapy to the chest wall, or breast local excision followed by radiotherapy. Indications for post-mastectomy radiotherapy are controversial but include the presence of multiple positive axillary lymph nodes, positive or narrow margins (less than 1mm), or large primary tumor size (greater than 5cm). Radiotherapy is indicated for most women after local excision of ductal carcinoma in situ (DCIS) or invasive carcinoma. In some women over the age of 70 who have been diagnosed with invasive breast cancer, radiation therapy may be safely omitted, especially if they have comorbidities.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member’s benefit plan.

Whole breast irradiation following breast-conserving surgery may be considered medically necessary for the following:

  • For an individual receiving radiation treatment to the whole breast with or without treatment to the low axilla, the use of a hypofractionated regimen is preferred.
    • This includes the use of up to 16 fractions of three-dimensional conformation radiation therapy (3DCRT) followed by up to 8 fractions of electrons or photons as a boost to the surgical bed.
  • For individuals not eligible for a hypofractionated regimen, the use of up to 28 fractions of 3DCRT followed by
    • Up to 8 fractions of electrons or photons as a boost to the surgical bed may be considered medically necessary.
  • Note that the boost to the surgical bed is planned using either electrons if using photons, a complex isodose technique.

A brachytherapy boost is considered not medically necessary.

The use of AccuBoost® is considered experimental/investigational, and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

The use of Intensity Modulated Radiation Therapy (IMRT) for treatment of the whole breast is considered not medically necessary.

Procedure Codes
77261, 77262 , 77263 , 77280 , 77285 , 77290 , 77293, 77295 , 77300 , 77301 , 77306 , 77307 , 77321 , 77331, 77332 , 77333 , 77334 , 77336 , 77338 , 77385 , 77387, 77402 , 77407 , 77412 , 77417 , 77427 , 0395T



Accelerated partial breast irradiation (APBI) following breast conserving surgery may be considered medically necessary when up to 10 fractions delivered twice daily of 3DCRT, IMRT or high dose rate (HDR) brachytherapy (intracavitary or interstitial) is used.

The use of AccuBoost® is considered experimental/investigational, and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes
77261, 77262, 77263, 77280, 77285, 77290, 77293, 77295, 77295, 77300, 77301, 77316, 77317, 77318, 77331, 77332, 77333, 77334, 77336, 77338, 77370, 77385, 77387, 77402, 77407, 77412, 77417, 77427, 77470, 77770, 77771, 77772, 77799, 0395T



The use of single fraction intraoperative radiation therapy (IORT) at the time of breast conserving surgery may be considered medically necessary for select node-negative individuals with invasive cancer in accordance with American Society for Radiation Oncology (ASTRO) guidelines as follows :

  • Electron-beam IORT may be considered medically necessary in a node-negative individual 50 years of age or older with invasive cancer and negative surgical margins; or
  • Consideration will be given for low-energy x-ray IORT (INTRABEAM®) when limited to a node-negative individual 50 years of age or older with invasive cancer and negative surgical margins who is enrolled in a prospective clinical trial or registry; or
  • In an individual who is found to have adverse pathologic features, supplemental radiation using up to 28 fractions of 3DCRT may be considered medically necessary.

The use of other forms of intraoperative brachytherapy, including but not limited to electronic brachytherapy is considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes
77261, 77262, 77263, 77280, 77285, 77290, 77293, 77295, 77300, 77331, 77332, 77333, 77334, 77336, 77370, 77402, 77407, 77412, 77417, 77424, 77425, 77427, 77469, 77470, 0395T



Post-mastectomy radiation may be considered medically necessary in an individual with positive axillary lymph node(s), a primary tumor greater than 5 cm or positive or close (< 1 mm) surgical margins when:

  • Up to 28 fractions of 3DCRT followed by up to 8 fractions of an electron boost may be considered medically necessary to the chest wall are used and, if needed, to regional nodes; or
  • The use of IMRT is considered not medically necessary.
Procedure Codes
77261, 77262, 77263, 77280, 77285, 77290, 77293, 77295, 77300, 77306, 77321, 77331, 77332, 77333, 77334, 77336, 77402, 77407, 77412, 77417, 77427



The use of up to 25 fractions of 3DCRT may be considered medically necessary for palliation.

Procedure Codes
77261, 77262, 77263, 77280, 77285, 77290, 77293, 77295, 77300, 77331, 77332, 77333, 77334, 77336, 77417, 77402, 77407, 77412, 77417


Place of Service: Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

Radiation therapy following breast conserving surgery is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.


The policy position applies to all commercial lines of business


Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

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Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages
If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.



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