Highmark Commercial Medical Policy - Pennsylvania |
Medical Policy: | R-73-002 |
Topic: | Radiation Therapy for Prostate Cancer |
Section: | Radiation Therapy & Nuclear Medicine |
Effective Date: | August 1, 2018 |
Issue Date: | July 30, 2018 |
Last Reviewed: | May 2018 |
Radiation therapy for prostate cancer may be used as the first treatment for cancer that is still just in the prostate gland; as part of the first treatment for cancers that have grown outside the prostate gland and into nearby tissues; if the cancer is not removed completely or comes back (recurs) in the area of the prostate after surgery; or if the cancer is advanced, to help keep the cancer under control for as long as possible and to help prevent or relieve symptoms. |
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 for prostate cancer may be considered medically necessary in the following situations:
Low-risk prostate cancer is defined as having ALL of the following:
Intermediate-risk prostate cancer is defined as having ANY of the following:
High-risk prostate cancer is defined as having ANY of the following:
Bone scans are recommended only for an individual with the following presentations:
Refer to medical policy R-18, Proton Beam Therapy, for additional information. |
Place of Service: Outpatient |
Radiation therapy for prostate 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.
Links |
05/2018, REMINDER: Radiation Therapy
01/2018, REMINDER: Radiation Therapy