Medical_Policy

Highmark Commercial Medical Policy - Pennsylvania

Medical Policy:	R-95-002
Topic:	Radiation Therapy for Skin Cancer
Section:	Radiation Therapy & Nuclear Medicine
Effective Date:	August 1, 2018
Issue Date:	July 30, 2018
Last Reviewed:	May 2018

Radiation therapy for skin cancer may be selected when cosmetic or functional outcome with surgery is expected to be inferior.

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.

Management of basal cell and squamous cell skin cancers

Photon and/or electron beam techniques may be considered medically necessary for the treatment of basal cell and squamous cell cancers of the skin for ANY of the following:
- Definitive treatment for a cancer in a cosmetically significant location in which surgery would be disfiguring; or
- Adequate surgical margins have not been achieved and further resection is not possible; or
- Definitive management of large cancers as an alternative to major resection requiring significant plastic repair; or
- Definitive management of large cancers that are considered inoperable; or
- Definitive, preoperative, or postoperative adjuvant therapy for cancers at risk for local or regional recurrence due to perineural, lymphovascular invasion, and/or metastatic adenopathy; or
- Definitive management for non-surgical candidates.
Contraindications to the use of photon and/or electron beam techniques:
- Radiation therapy should not be used in genetic conditions which predispose to skin cancer, such as xeroderma pigmentosum or basal cell nevus syndrome; or
- Radiation treatments should be avoided or only used with great caution in cases of connective tissue disorders.
Brachytherapy (low dose rate [LDR], high dose rate [HDR], surface, or interstitial technique) may be considered medically necessary when the following are contraindicated:
- Surgical resection; or
- Photon and/or electron beam techniques.
Electronic brachytherapy may be considered medically necessary for the treatment of basal cell and squamous cell skin cancers;
- When brachytherapy is required for treatment of skin cancers, up to ten (10) sessions may be considered medically necessary.
Superficial or kilovoltage (kV) xray treatments with low energy (up to 250 kV) external beam devices are generally used for thinner lesions. The beam energy and hardness (filtration) dictate the maximum thickness of a lesion that may be treated with this technique.

Procedure Codes

77261, 77262, 77263, 77280, 77285, 77290, 77293, 77295, 77300, 77301, 77306, 77307, 77316, 77317, 77318, 77321, 77331, 77332, 77333, 77334, 77336, 77338, 77370, 77373, 77385, 77386, 77387, 77401, 77402, 77407, 77412, 77417, 77427, 77431, 77435, 77470, 77520, 77522, 77523, 77525, 77761, 77762, 77763, 77767, 77768, 77778, 0394T, G0339, G0340

Management of malignant melanoma

· Photon and/or electron beam techniques may be considered medically necessary in the treatment of malignant melanoma at the primary site of the skin in these situations:

o Adjuvant treatment after resection of a primary deep desmoplastic melanoma with close margins;

o Adjuvant treatment after resection of the primary tumor and the specimen shows evidence of extensive neurotropism;

o Locally recurrent disease after resection;

· Photon and/or electron beam techniques may be considered medically necessary in the treatment of regional (i.e. those with nodal involvement) malignant melanoma in these situations:

o Upon resection of clinically appreciable lymph nodes when:

§ The lactate dehydrodgenase (LDH) level is less than 1.5 times the upper limit of normal; and

§ Extranodal extension of tumor is present in the resected nodes; and

§ ONE or MORE of the following;

· One or more involved parotid lymph nodes of any size

· Two or more involved cervical lymph nodes and/or tumor within a node is 3 cm or larger

· Two or more involved axillary lymph nodes and/or tumor within a node is 4 cm or larger

· Three or more involved inguinal lymph nodes and/or tumor within a node is 4 cm or larger;

· Photon and/or electron beam techniques may be considered medically necessary to palliate unresectable nodal, satellite, or in-transit disease;

· Photon and/or electron beam techniques may be considered medically necessary in the treatment of metastatic malignant melanoma in these situations:

o Symptomatic or potentially symptomatic soft tissue metastases;

o Symptomatic or potentially symptomatic bone metastases;

o Symptomatic or potentially symptomatic visceral metastases;

o Metastases to the brain.

Procedure Codes

77261, 77262, 77263, 77280, 77285, 77290, 77321, 77331, 77332, 77333, 77334, 77336, 77412, 77417, 77427, 77431

Refer to medical policy R-65, Radiation Therapy for Bone Metastases, for additional information.

Refer to medical policy R-21, Radiation Therapy for Brain Metastases, for additional information.

Place of Service: Outpatient

Radiation therapy for skin 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

Link to Provider Resource Center for the Medical Policy Update

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

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.