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.

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.

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.

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.

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.

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

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.

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.

• Link to Provider Resource Center for the Medical Policy Update

05/2018, REMINDER: Radiation Therapy
01/2018, REMINDER: Radiation Therapy

• Link to References