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| Medical Policy: | R-90-002 |
| Topic: | Radiation Therapy for Non-malignant Disease |
| Section: | Radiation Therapy & Nuclear Medicine |
| Effective Date: | August 1, 2018 |
| Issue Date: | July 30, 2018 |
| Last Reviewed: | May 2018 |
Benign disorders do not always follow a benign course, so radiation was employed for many conditions for which there was no suitable therapeutic alternative. As improvements in competing therapies have been developed, such as antibiotics, antifungals, antivirals, chemotherapies, improved surgical techniques, and immunological therapy, radiation therapy is no longer appropriate for many disorders, yet has become the preferred therapy for others. |
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. |
Non-malignant disorders for which radiation therapy may be considered medically necessary when criteria are met:
- Angiomatosis retinae (von Hippel Lindau syndrome)
- Conventional photon external beam radiation therapy (EBRT) in those cases in which a simpler approach is contraindicated.
- Arteriovenous malformation (AVM)
- Stereotactic radiosurgery (SRS) for
- deep or eloquently-located AVMs less than 3 cm in size, for which surgery poses a greater risk
- lesions elsewhere in the brain that require treatment and surgical excision is not an option
- Stereotactic radiosurgery (SRS) for
- Basalioma
- Carotid body tumor (see chemodectoma)
- Cavernous malformation (see AVM)
- Chemodectoma (carotid, glomus jugulare, aortic body, glomus vagale, glomus tympanicum [chromaffin negative])
- Chordoma (also see separate Guideline, Proton Beam Radiation Therapy)
- Choroidal hemangioma (also see separate Guideline, Proton Beam Radiation Therapy)
- Craniophayngioma (also see separate Guideline, Proton Beam Radiation Therapy)
- Desmoid tumor
- Dupuytren’s contracture (fibromatosis)
- Eosinophilic granuloma (see Langerhans cell histiocytosis)
- Exophthalmos (refer to specific etiology)
- Extramammary Paget’s disease (adenocarcinoma of the skin)
- Extramedullary hematopoiesis (hypersplenism)
- Giant cell tumor of bone (osteoclastoma)
- Glomus jugulare (see chemodectoma)
- Glomus tympanicum (see chemodectoma)
- Glomus vagale (see chemodectoma)
- Gorham-Stout syndrome (disappearing bone syndrome)
- Graves’ ophthalmopathy
- Gynecomastia
- Hemangiomas
- Heterotopic ossification
- Histiocytosis (see Langerhans cell histiocytosis)
- Hypersalivation of amyotropic lateral sclerosis (ALS)
- Hypersplenism (see Splenomegaly)
- Hyperthyroidism
- Keloid scar
- Langerhans cell histiocytosis
- Lethal midline granuloma
- Meningioma
- Morbus Ledderhose
- Optic pathway glioma
- Osteoarthritis
- Paraganglioma (chromaffin positive)
- Parotid adenoma
- Peyronie’s disease (morbus peronie, induratio penis plastica)
- Pigmented villonodular synovitis (tenosynovial giant cell tumor)
- Pinealoma (pineal parenchymal tumors)
- Pituitary adenoma
- Plantar fasciitis
- Polymorphic reticulosis (see lethal midline granuloma)
- Precancerous melanosis
- Psoriasis
- Pterygium
- Splenomegaly
- Stent placement
- Steward’s disease (see lethal midline granuloma)
- Vertebral hemangioma (hemangioma)
Non-malignant disorders for which radiation therapy may be considered medically necessary when criteria are met:
Note: all requests require review on a case-by-case basis
- Acoustic neuroma (vestibular schwannoma)
- the use of single-fraction SRS and fractionated SRS may be considered medically necessary for those cases in which surgery is declined or not indicated
- Adamantinoma (ameloblastoma)
- Aneurysmal bone cyst
- Must be accompanied by documentation that its use is considered essential by a multi-disciplinary team
- Angofibroma of nasopharynx (juvenile nasopharyngeal angiofibroma)
- In those cases with extension into the orbital apex or base of skull
- Bowen’s disease (squamous cell carcinoma in situ)
- Only when no other reasonable alternative exists
- Bronchial adenoma
- Only when no other reasonable alternative exists
- Bursitis, synovitis, tendonitis
- Only when no other reasonable alternative exists
- Carcinoid tumor
- Only when no other reasonable alternative exists
- Castleman’s disease (giant lymph node hyperplasia)
- Castration
- Only when no other reasonable alternative exists
- Choroid plexus papilloma
- Only when no other reasonable alternative exists
- Cystic hygroma (lymphangioma) (see Lymphangioma)
- Dermatitis
- Only when alternative approaches have been exhausted
- Epilepsy
- Only when medical management has been exhausted and unsatisfactory
- Erythroplasia of Queyrat
- Only when no other reasonable alternative exists
- Immunosuppression
- Infections (viral)
- Only when non-radiation alternatives have been exhausted
- Inverted papilloma
- Only when no other reasonable alternative exists
- Lymphangiomas (capillary, cavernous, cystic hydromas, lymphangeal hemangiomas)
- Only when no other reasonable alternative exists
- Lymphoma “benign”
- Mikulicz syndrome (salivary lymphoepithelial lesion)
- Only when no other reasonable alternative exists
- Myasthenia gravis (see Thymoma)
- Neurofibroma (benign, von Recklinhausen)
- Only when no other reasonable alternative exists
- Orbital myositis
- Only when no other reasonable alternative exists
- Orbital pseudotumor
- Only when no other reasonable alternative exists
- Parkinson’s disease
- Only when non-radiation alternatives have been exhausted
- Persistent lymphatic fistula
- Only when non-radiation alternatives have been exhausted
- Pseudotumor (orbit)
- Rosai-Dorfman disease
- Only when non-radiation alternatives have been exhausted
- Rotator cuff syndrome (see tendonitis)
- Sarcoidosis
- Only when non-radiation alternatives have been exhausted
- Sterilization (see castration)
- Synovitis
- Only when non-radiation alternatives have been exhausted
- Tendonitis
- Only for those cases not responding to conservative measures
- Tennis elbow (see tendonitis)
- Thymoma
- Tolosa-Hunt syndrome (episodic orbital pain)
- Only when non-radiation alternatives have been exhausted
- Total body irradiation
- Total lymphoid irradiation
- Only when non-radiation alternatives have been exhausted
- Trigeminal neuralgia (tic douloureux)
- Warts
- Only when non-radiation alternatives have been exhausted
Non-malignant disorders for which radiation therapy 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:
- Abortion
- Acne
- Amyloidosis
- Ankylosing spondylitis
- Anovulation
- Arachnoiditis
- Arthritis (also see Total Lymphoid Irradiation for radioimmunosuppression)
- Corneal vascularization
- Corneal xanthogranuloma
- Eczema
- Fibrosclerosis (sclerosing disorders)
- Fungal infections
- Gas gangrene
- Herpes zoster
- Infections (bacterial)
- Infections (fungal and parasitic)
- Inflammatory (acute/chronic) disorders not responsive to antibiotics (furuncles, carbuncles, sweat gland abscesses)
- Juvenile xanthogranuloma
- Keratitis (bullous and filamentary)
- Macular degeneration
- Orbital myositis
- Ocular trichiasis (epilation)
- Orbital pseudotumor (lymphoid hyperplasia)
- Osteoid osteoma (osteoblastoma, giant osteoid osteoma)
- Otitis media
- Pancreatitis
- Parotitis
- Peptic ulcer disease
- Perifolliculitis (scalp)
- Plasma cell granuloma (benign)
- Pregnancy
- Pseudotumors (orbit) (see orbital pseudotumor)
- Psychiatric disorders
- Pyogenic granuloma
- Rheumatoid arthritis
- Sclerosing disorders (see fibrosclerosis)
- Sinusitis
- Thyroiditis
- Tinea (see infections [fungal])
- Tonsillitis
- Tuberculosis lymphadenitis
- Vernal catarrh
Refer to medical policy R-95 Radiation Therapy for Skin Cancer for additional information. |
| Place of Service: Outpatient |
Radiation therapy for non-malignant diseases 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.
| Links |
- Link to Provider Resource Center for the Medical Policy Update
05/2018, REMINDER: Radiation Therapy
01/2018, REMINDER: Radiation Therapy
 |
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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