| Highmark Commercial Medical Policy - Pennsylvania |
| Medical Policy: | R-4-022 |
| Topic: | Radiation Therapy |
| Section: | Radiation Therapy & Nuclear Medicine |
| Effective Date: | February 13, 2017 |
| Issue Date: | February 13, 2017 |
| Last Reviewed: | January 2017 |
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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. |
This policy includes frequency standards considered appropriate in the majority of cases involving radiation therapy treatment planning and delivery. However, each patient’s unique clinical circumstances may warrant individual consideration based on a review of applicable medical records. Examples of when an allowance for more frequent services may be warranted include, but are not limited to:
Clinical treatment planning develops an appropriate plan or course of action necessary to treat the patient’s condition. During the planning process, the radiation oncologist works closely with the medical physicist and dosimetrist to identify the appropriate course of treatment. This includes, but is not limited to:
A clinical course of radiation therapy consists of one treatment plan per course of therapy. It is usually performed prior to the initiation of treatment. Multiple treatment plans for a single course of treatment is not considered medically necessary. However, when there is a substantive change in the patient’s tumor or general condition, the new or revised course of treatment may require a new treatment plan. Treatment planning is a professional service only code.
The prescribed plan must be clearly documented in the patient’s medical records and available for review upon request.
Simulation-aided field setting directs or aims the treatment beams to the specific treatment volume (the size and shape of the tumor) identified in clinical treatment planning. This process includes determining the optimal patient and equipment positioning for treatment, beam entry sites, and treatment devices. The complexity of simulation is based on the number of ports of beam entry, treatment volumes, and the use and type of any treatment devices needed to shield or protect adjacent healthy organs or tissue.
The typical course of radiation therapy consists of between one and three simulations. Portal changes based on unsatisfactory initial simulations should not be reported as additional simulations.
Additional simulations may be necessary during a course of treatment to account for changes in port size, boost dose, or tumor volume, for example, when a new field is treated, or, when the geometry of a treatment field changes. Minor changes in port size do not warrant an additional allowance.
The medical necessity for each simulation must be documented in the patient’s clinical records.
Basic dosimetry is a mathematical calculation of the radiation dose to the tumor volume. This service may be considered medically necessary for each treatment field or port.
Only one dosimetry calculation is eligible when there is no change in dosimetry parameters. Additional calculations may be necessary when a patient has off-axis calculations, calculations for different depth doses, different target areas, secondary film dosimetry, abutting fields, or any other situation requiring individual point calculations for radiation dosage.
Teletherapy isodose plans ensure that the treatment volume (tumor) receives the prescribed dose of radiation. Teletherapy is the delivery of radiation treatments to a patient from equipment located remote from the body.
One (1) isodose plan is necessary for a course of therapy to a specific treatment area. Additional isodose plans may be considered medically necessary when there is a need to change the method of treatment delivery, or there is a change in tumor volume.
Other examples of when additional isodose plans may be necessary include but are not limited to:
Multiple points of calculation within an isodose plan should not be reported individually. This is considered a single service.
Special teletherapy port planning is performed when any special beam considerations are necessary. Some examples include the use of electrons in total skin irradiation, photons for hemibody irradiation, and proton or neutron beam therapy planning. The radiation oncologist must document his or her involvement in the planning, the selection of the special beam parameters, and the initiation of the treatment process.
This service should only be reported once per day or per volume of interest. In addition, a special teletherapy port plan is an electron calculation.
Brachytherapy isodose plans
Brachytherapy is a method of delivering ionizing radiation whose source is applied to the surface of the body or within the body a short distance from the area being treated. It is used to improve control of local disease, treat areas at high risk for recurrence of malignancy, preserve vital organ function, and minimize damage to surrounding normal tissue or organs.
The isodose calculations determine the amount of radiation that will be absorbed by the tumor per implant or for the entire course of treatment for permanent implants. From this calculation, the treatment course can be modified as needed by increasing or decreasing the patient’s exposure to the isotope.
One brachytherapy isodose plan is performed per course of treatment or per implantation when the position of the sources varies from one implant to another.
Special dosimetry measures the radiation dose at a given point using special radiation monitoring and measuring devices. The results of these measurements aid in determining whether to accept or revise the current treatment plan.
Special dosimetry is performed once per port when the physician determines that it is necessary to have a measurement of the amount of radiation a patient has actually received at a given point. It is not routinely performed each time the patient is treated.
When special dosimetry is used, the typical frequency will be between one and six in total during a course of radiation therapy.
Treatment devices (design and construction) are used when it is necessary to shield or protect normal, healthy critical structures from unnecessary irradiation.
There are many different treatment devices. The type of device(s) used or constructed is determined by the radiation oncologist’s clinical evaluation of the patient’s anatomy and disease state.
Treatment devices should be reported at the onset of treatment. They may be replaced during treatment if additional or new devices are necessary. Medically necessary changes in beam geometry or port configuration may occur during a course of treatment. This may require the redesign and fabrication of new treatment devices.
Payment for an individual treatment device is limited to once for the entire course of treatment, regardless of the number of times that device is actually used.
Pre-made, multiple-patient use, standard shaped blocks (for example, beam splitter blocks, two or four corner pelvis blocks, and midline cord blocks) are not considered custom blocks. Products used for patient comfort, such as pillows, pads, cushions, etc., are not considered treatment devices in this instance and are not eligible for payment.
The use of passive restraints (for example, straps and sandbags, etc.) is not eligible for separate payment.
A course of radiation therapy may necessitate the design and construction of different devices, depending on the patient’s condition, treatment plan, and/or method of radiation treatment delivery. However, payment for an individual treatment device is limited to once for the entire course of treatment, regardless of the number of times that device is actually used.
Continuing medical physics consultation represents the ongoing medical physics assessment provided to all patients receiving radiation therapy. The patient’s chart is reviewed to ensure that the radiation treatment administered conforms to the treatment parameters prescribed by the radiation oncologist. This assessment includes verification of accurate dose calculations, accurate data entry in the patient’s chart, proper patient positioning and beam orientation, patient radiation safety, and correct summation of dose at the conclusion of treatment. An examination of the patient setup may also be required to ensure the correct placement of any treatment devices or beam modifiers.
Code 77336 is considered a “weekly” code and should be reported once for each week (5 treatments) of therapy.
The date of service reported for code 77336 should be the date of the last treatment for a particular “week” of therapy. If, at the final billing of the treatment course there are three or four fractions beyond a multiple of five, those three or four fractions should be considered a "week."
Code 77336 represents a technical service only. As such, the service is reimbursed as a technical component only.
A special medical radiation physics consultation may be necessary when a problem or unusual situation presents requiring a special evaluation, or if the patient is off treatment for any reason for a significant period of time. In these instances, the information acquired from this physics consultation would be used to design or modify the current treatment plan.
An example of a situation that may require a special physics consultation is as follows:
A special physics consultation is typically performed once per course of radiation therapy.
Therapeutic radiology port image(s) are taken on the treatment machine using the treatment beam to ensure the therapy is delivered as prescribed by the simulation and dosimetry. Port images produced by each treatment beam unit are compared with digitally reconstructed images to verify that the treatment beams and fields planned at the time of simulation are synchronous.
Any changes indicated by the port films must be incorporated into the treatment plan. Therapeutic radiology port images are limited to one per week.
Radiation treatment delivery are technical component only services and recognizes the various energy levels (MeV) administered to the patient as well as the area(s) treated. It is important to report the code for the actual procedure ordered and performed. An area is an anatomically identifiable region, for example the neck, throat, bone, breast or prostate. An area may be treated using one or more ports. ( e.g. the right and left neck is considered one area, however brain and lung would be considered two areas).
Radiation therapy treatment delivery codes are eligible on a per treatment basis. Multiple treatments on the same day are eligible, provided there has been a distinct break in therapy services (for example, morning and afternoon treatment sessions).
Procedure code 77401 represents radiation treatment delivery using superficial and/or ortho voltage. This type of treatment is typically used for delivering radiation treatment to superficial skin lesions. It is eligible once per day.
Clinical Treatment Management is only used for external beam radiation therapy treatments. Clinical treatment management should be reported in units of five treatments or fractions regardless of the actual time period in which the services are furnished. These treatments do not need to be furnished on consecutive days. There are four services typically included in treatment management:
A weekly unit of treatment management is equal to five fractions, regardless of whether those fractions are on consecutive days. If, at the final billing of the treatment course there are three or four fractions beyond a multiple of five, those three or four fractions should be considered a week.
Three or four fractions are not eligible if there is no indication that the course of treatment has ended. Also, if there are one or two fractions beyond a multiple of five, the number will be rounded down.
Example:
18 fractions = 4 weekly services
8 fractions = 2 weekly services
6 fractions = 1 weekly service
Code 77431 is used when only one or two fractions are provided as an independent course of treatment. This code should not be used to fill the last week of a longer course of treatment.
Brachytherapy may be used to treat benign or malignant conditions. It can be performed as part of a treatment protocol involving external beam radiation therapy and other modalities such as surgery or chemotherapy, or it can be delivered independently as the sole method of treatment.
In some cases, brachytherapy may be performed concomitantly with surgical resection, or in conjunction with surgical procedures such as endoscopy or angioplasty, when access to the site of the disease requires this intervention. As such, brachytherapy may require the professional expertise and services of other specialists in addition to the radiation oncologist. These specialists perform related-but-separate procedures before, during or after the brachytherapy procedure. In most cases, when different providers are involved in the brachytherapy treatment (e.g., a surgeon, radiation oncologist, and/or radiologist), each provider should only be reimbursed for the services he or she actually performs.
Supervision, handling, and loading of radioelements should only be reported with manual-loading low dose radiation brachytherapy. The service includes receipt, radioactivity assay and storage of the material. It also includes custom preparation of the radioactive sources for loading, such as any modifications of seeds in ribbons and pre-loading the permanent seeds into insertion devices.
Code Q3001 should be used to report radioelements for brachytherapy when the brachytherapy is performed in other than a facility setting.
High dose rate electronic brachytherapy is considered experimental/investigational for all conditions and uses. There is insufficient scientific peer-reviewed literature published comparing the results obtained through the use of electronic brachytherapy versus standard radioisotope-based brachytherapy. In addition, prospective clinical studies are needed to determine the procedure’s efficacy in short and long term patient outcomes, rates of recurrence, patient toxicity, patient selection criteria, standardized performance protocols, and patient safety. Claims reporting this service will be denied as experimental/investigational.
Radiation therapy treatments for benign conditions
Pre and/or post-operative radiation treatment is eligible when it is performed to minimize post-operative heterotopic ossification following an orthopedic surgical procedure.
Radiation therapy used to treat the following nonmalignant conditions is considered to be of questionable current usefulness:
In these instances, documentation must substantiate the medical necessity in each patient’s case. Services performed in conjunction with radiation therapy for these conditions are eligible only if the radiation therapy in question is eligible.
Special treatment procedures represent the physician’s professional service and the technical component required for special procedures and is eligible once per course of treatment.
Hyperfractionation is the delivery of radiation in smaller than usual doses, more than once per day. The technique usually requires delivery of two fractions daily, each fraction being a little more than half the dose given in a usual daily schedule.
The standard weekly management codes should be used for these treatments, with the number of fractions divided by two to determine the number of daily treatments.
The number of daily treatments should then be divided by five to determine the number of weekly treatments.
EXAMPLE:
10 fractions/2 = 5 days
5 days/5 = 1 week
When medical care and radiation therapy treatment management are reported by one doctor or his associate on the same day, only the highest paying service is reimbursed. The medical necessity for radiation therapy services described in this policy must be documented in the patient’s clinical records and be available for review upon request. |
| Place of Service: Inpatient/Outpatient |
Experimental/Investigational (E/I) services are not covered regardless of place of service.
Radiation Therapy 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 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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