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| Medical Policy: | R-65-002 |
| Topic: | Radiation Therapy for Bone Metastases |
| Section: | Radiation Therapy & Nuclear Medicine |
| Effective Date: | August 1, 2018 |
| Issue Date: | July 30, 2018 |
| Last Reviewed: | May 2018 |
Bone is a common site of metastatic cancer. Photon techniques are the mainstay of treatment for symptomatic bone metastases. Local field radiotherapy is highly effective in relieving pain and preventing fractures and is typically associated with minimal side effects. |
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. |
Up to 10 fractions of radiation planned using a complex isodose technique may be considered medically necessary in the palliative treatment of bone metastases using the following techniques.
- Complex isodose technique:
- As the ports (beams) used to target and treat the metastasis are often modified, a complex teletherapy isodose plan in addition to a simple teletherapy isodose plan may be considered medically necessary for the treatment of bone metastasis.
- Three-dimensional (3D) Conformal Radiation Therapy (3DCRT) and Intensity- Modulated Radiation Therapy (IMRT):
- Use of conformal radiation therapy techniques including 3DCRT and IMRT generally is not medically necessary for the treatment of bone metastasis.
- 3DCRT will be considered when there is a significant complex extraosseous component to the target volume.
- 3DCRT and IMRT will be considered in cases where overlap with previous radiotherapy fields is likely to cause complications.
- Stereotactic Body Radiosurgery (SBRT):
- SBRT may be considered in cases that require treatment to a portion of the spine that has been previously irradiated.
- SBRT may also be considered for treatment of sarcoma, melanoma, and renal cell carcinoma that have metastasized to the spine.
Radium-223 (Xofigo®) is considered medically necessary for the treatment of castration-resistant prostate cancer for an individual with ALL the following:
- The individual has symptomatic skeletal (bone) metastases; and
- The individual has no evidence of visceral metastases or bulky regional lymph nodes greater than three (3) cm on imaging performed within the past 30 days; and
- The individual has received and exhausted all medical- or surgical-ablative hormonal treatments. The individual may be kept on ablative hormonal treatment to maintain a castrate level in accordance with NCCN® guidelines; and
- Medically- or surgically-castration resistant prostate cancer, as defined by
- A serum testosterone level of less than 50 ng/dL and EITHER
- Sequential rise of prostate specific antigen (PSA) levels; or
- Worsening of existing bone metastases or development of new bone metastases on a bone scan performed within the past 60 days despite androgen-deprivation treatment
Concurrent chemotherapy with Xofigo® is considered experimental/investigational, and therefore, non-covered beacause the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
Refer to medical policy R-14, Radiation Therapy for Oligometastases, for additional information.
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| Place of Service: Outpatient |
Experimental/Investigational (E/I) services are not covered regardless of place of service.
| 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.
| Links |
- Link to Provider Resource Center for the Medical Policy Update
05/2018, REMINDER: Radiation Therapy
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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.
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Room 509F, HHH Building
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1-800-368-1019, 800-537-7697 (TDD)
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