Highmark Commercial Medical Policy - Pennsylvania

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Medical Policy: R-73-002
Topic: Radiation Therapy for Prostate Cancer
Section: Radiation Therapy & Nuclear Medicine
Effective Date: August 1, 2018
Issue Date: July 30, 2018
Last Reviewed: May 2018

Radiation therapy for prostate cancer may be used as the first treatment for cancer that is still just in the prostate gland; as part of the first treatment for cancers that have grown outside the prostate gland and into nearby tissues; if the cancer is not removed completely or comes back (recurs) in the area of the prostate after surgery; or if the cancer is advanced, to help keep the cancer under control for as long as possible and to help prevent or relieve symptoms.

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.

Radiation therapy for prostate cancer may be considered medically necessary in the following situations:

  • Monotherapy with three-dimensional conformal radiation therapy (3DCRT), intensity-modulated radiation therapy (IMRT), radioactive seed implant, or high dose rate (HDR) brachytherapy when the individual meets both of the following:
    • Low- and intermediate-risk prostate cancer; and
    • Negative bone scan within the last 6 months, where applicable.
  • External beam photon radiation therapy (3DCRT or IMRT) alone or combined with brachytherapy (HDR or radioactive seed implant)
    • Intermediate-risk and high-risk prostate cancer
    • Negative bone scan within the past 6 months, where applicable.
  • Stereotactic body radiation therapy (SBRT) alone
    • Low-, intermediate-, and high-risk prostate cancer
    • Negative bone scan within the last 6 months, where applicable.
  • External beam photon radiation therapy (3DCRT or IMRT) in the postoperative setting for at least ONE of the following:
    • Positive surgical margins; or
    • Extracapsular extension; or
    • Seminal vesicle involvement; or
    • Positive lymph nodes; or
    • Detectable or rising postoperative PSA level.
  • Palliative
    • Treatment for obstructive symptoms or hematuria due to tumor may be considered medically necessary.
Procedure Codes
76873, 77261, 77262, 77263, 77280, 77285, 77290, 77295, 77300, 77301, 77316, 77317, 77318, 77332, 77333, 77334, 77336, 77338, 77370, 77373, 77385, 77387, 77402, 77407, 77412, 77417, 77427, 77435, 77470, 77520, 77522, 77523, 77525, 77778, G0339, G0340

Low-risk prostate cancer is defined as having ALL of the following:

  • Stage T1 to T2a; and
  • Gleason score (GS) less than or equal to six (6); and
  • Prostate specific antigen (PSA) less than 10 ng/mL

Intermediate-risk prostate cancer is defined as having ANY of the following:

  • Stage T2b to T2c; or
  • Gleason score (GS) is seven (7); or
  • PSA 10 to 20 ng/mL

High-risk prostate cancer is defined as having ANY of the following:

  • Stage greater than or equal to T3a; or
  • Gleason score (GS) greater than or equal to eight (8); or
  • PSA greater than 20 ng/mL

Bone scans are recommended only for an individual with the following presentations:

  • T1 and PSA greater than 20
  • T2 and PSA greater than 10
  • GS greater than eight (8)
  • T3, T4
  • Symptomatic

Refer to medical policy R-18, Proton Beam Therapy, for additional information.

Place of Service: Outpatient

Radiation therapy for prostate cancer 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.


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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