Medical_Policy

Highmark Commercial Medical Policy - Pennsylvania

Medical Policy:	R-65-002
Topic:	Radiation Therapy for Bone Metastases
Section:	Radiation Therapy & Nuclear Medicine
Effective Date:	August 1, 2018
Issue Date:	July 30, 2018
Last Reviewed:	May 2018

Bone is a common site of metastatic cancer. Photon techniques are the mainstay of treatment for symptomatic bone metastases. Local field radiotherapy is highly effective in relieving pain and preventing fractures and is typically associated with minimal side effects.

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.

Up to 10 fractions of radiation planned using a complex isodose technique may be considered medically necessary in the palliative treatment of bone metastases using the following techniques.

Complex isodose technique:
- As the ports (beams) used to target and treat the metastasis are often modified, a complex teletherapy isodose plan in addition to a simple teletherapy isodose plan may be considered medically necessary for the treatment of bone metastasis.
Three-dimensional (3D) Conformal Radiation Therapy (3DCRT) and Intensity- Modulated Radiation Therapy (IMRT):
- Use of conformal radiation therapy techniques including 3DCRT and IMRT generally is not medically necessary for the treatment of bone metastasis.
- 3DCRT will be considered when there is a significant complex extraosseous component to the target volume.
- 3DCRT and IMRT will be considered in cases where overlap with previous radiotherapy fields is likely to cause complications.
Stereotactic Body Radiosurgery (SBRT):
- SBRT may be considered in cases that require treatment to a portion of the spine that has been previously irradiated.
- SBRT may also be considered for treatment of sarcoma, melanoma, and renal cell carcinoma that have metastasized to the spine.

Procedure Codes

77261, 77262, 77263, 77280, 77285, 77290, 77293, 77295, 77300, 77301, 77306, 77307, 77321, 77331, 77332, 77333, 77334, 77336, 77338, 77370, 77373, 77385, 77386, 77387, 77402, 77407, 77412, 77417, 77427, 77431, 77435, 77470, 77520, 77522, 77523, 77525, G0339, G0340

Radium-223 (Xofigo®) is considered medically necessary for the treatment of castration-resistant prostate cancer for an individual with ALL the following:

The individual has symptomatic skeletal (bone) metastases; and
The individual has no evidence of visceral metastases or bulky regional lymph nodes greater than three (3) cm on imaging performed within the past 30 days; and
The individual has received and exhausted all medical- or surgical-ablative hormonal treatments. The individual may be kept on ablative hormonal treatment to maintain a castrate level in accordance with NCCN® guidelines; and
Medically- or surgically-castration resistant prostate cancer, as defined by

A serum testosterone level of less than 50 ng/dL and EITHER

Sequential rise of prostate specific antigen (PSA) levels; or
Worsening of existing bone metastases or development of new bone metastases on a bone scan performed within the past 60 days despite androgen-deprivation treatment

Concurrent chemotherapy with Xofigo® is considered experimental/investigational, and therefore, non-covered beacause the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

79101, A9606, A9699

Refer to medical policy R-14, Radiation Therapy for Oligometastases, for additional information.

Place of Service: Outpatient

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

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

Link to Diagnosis Codes

Link to References

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.