Highmark Commercial Medical Policy - Pennsylvania

Medical Policy: R-68-002
Topic: Radiation Therapy for Head and Neck Cancer
Section: Radiation Therapy & Nuclear Medicine
Effective Date: August 1, 2018
Issue Date: July 30, 2018
Last Reviewed: May 2018

Radiation therapy is considered an integral component in the multidisciplinary management of malignancies of the head and neck region. Primary anatomic sites included in this category include paranasal sinuses (ethmoid and maxillary), salivary glands, the lip, oral cavity, oropharynx, hypopharynx, glottic larynx, supraglottic larynx, nasopharynx, and occult/unknown head and neck primary sites.

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.

Radiation therapy techniques  

Procedure Codes
77261, 77262, 77263, 77280, 77285, 77290, 77295, 77300, 77301, 77306, 77307, 77321, 77331, 77332, 77333, 77334, 77336, 77338, 77370, 77385, 77386, 77387, 77402, 77407, 77412, 77417, 77423, 77427, 77520, 77522, 77523, 77525



Radiation therapy treatment intent/timing

Procedure Codes
77261, 77262, 77263, 77280, 77285, 77290, 77295, 77300, 77301, 77306, 77307, 77321, 77331, 77332, 77333, 77334, 77336, 77338, 77370, 77385, 77386, 77387, 77402, 77407, 77412, 77417, 77423, 77427, 77520, 77522, 77523, 77525



Radiation therapy, brachytherapy

Procedure Codes
77263, 77280, 77285, 77290, 77295, 77316, 77317, 77318, 77332, 77336, 77370, 77470, 77761, 77762, 77763, 77770, 77771, 77772, 77778



Radiation therapy, palliative

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



Re-treatment for salvage after prior radiation

Procedure Codes
77261, 77262, 77263, 77280, 77285, 77290, 77295, 77300, 77301, 77331, 77332, 77333, 77334, 77336, 77338, 77370, 77373, 77435, 77470, G0339, G0340



Refer to medical policy R-64, Neutron Beam Therapy, for additional information.


Professional Statements and Societal Positions

 

Per the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Head and Neck Cancers, “In general, the reirradiated population of head and neck cancer patients as described in the current literature represents a diverse but highly selected group of patients treated in centers where there is a high level of expertise and systems in place for managing acute and long-term toxicities. When the goal of treatment is curative and surgery is not an option, reirradiation strategies can be considered for patients who: develop locoregional failures or second primaries at greater than or equal to six(6) months after the initial radiotherapy; can receive additional doses of radiotherapy of at least 60 Gy; and can tolerate concurrent chemotherapy. Organs at risk for toxicity should be carefully and analyzed through review of dose volume histograms, and consideration for acceptable doses should be made on the basis of time interval since original radiotherapy, anticipated volumes to be included, and patient’s life expectancy.”


Place of Service: Outpatient

Radiation therapy for head and neck cancer 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.

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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.

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.