Highmark Commercial Medical Policy - Pennsylvania
Medical Policy: R-14-009
Topic: Radiation Therapy for Oligometastases
Section: Radiation Therapy & Nuclear Medicine
Effective Date: August 1, 2018
Issue Date: July 30, 2018
Last Reviewed: May 2018

Oligometastases is described as an intermediate state in the spread of cancer between early-stage localized disease and widespread metastases. Specifically, it is a malignancy that has progressed to a limited number of hematogenous metastatic sites, defined in most studies as one (1) to three (3) sites. Synchronous Oligometastatic is disease found at the time of the diagnosis of the primary tumor. Metachronous Oligometastatic is disease found after treatment of the primary tumor. Oligoprogression is progression of a limited number of metastatic sites while other metastatic disease sites remain controlled.

Stereotactic Body Radiotherapy (SBRT) or Stereotactic Ablative Radiotherapy (SABR) has been investigated as an alternative to surgical resection in the treatment of oligometastatic disease. SBRT offers greater precision to a limited target volume than previous radiation delivery technologies.

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.

SBRT for extra-cranial oligometastases may be considered medically necessary in the following clinical situations:

SBRT is considered not medically necessary for an individual with oligoprogressive non-small cell lung disease.

SBRT to greater than three (3) sites 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.

SBRT use to stimulate the abscopal effect is considered not medically necessary.

NOTE: All eviCore cases will require review of the consultation note and the most recent positron emission tomography (PET) scan (demonstrating no evidence of widespread metastatic disease) by their radiation oncologist.

Procedure Codes
77261, 77262, 77263, 77280, 77285, 77290, 77293, 77295, 77300, 77301, 77331, 77332, 77333, 77334, 77336, 77338, 77370, 77373, 77385, 77386, 77387, 77402, 77407, 77412, 77417, 77427, 77435, 77470, G0339, G0340


Place of Service: Outpatient

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

SBRT 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: 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.

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