Notification

Radiation Therapy Services


Notification Issue Date: 10/21/2019

This version of the policy will become effective 01/21/2020.

eviCore healthcare has revised their Radiation Therapy Clinical Guidelines. These guidelines will become effective 01/21/2020. These guidelines are available online at: https://www.evicore.com/resources/Pages/providers.aspx.

The following HCPCS codes were added to Attachment A of this policy: A4648, A4650, A9517, A9527, A9530, A9563, A9564, A9600, A9604, C1715, C1716, C1717, C1719, C2634, C2635, C2636, C2637, C2638, C2639, C2640, C2641, C2642, C2643, C2644, C2698, C2699, C9725, C9728
_______________________________________________________________

Note: On 12/04/2019, Attachment A of this policy was updated to incorporate coding changes effective 01/01/2020.

The following HCPCS code was added to Attachment A of this policy: A9590

The following HCPCS code was removed from Attachment A of this policy: C9408



Medicare Advantage Policy

Title:Radiation Therapy Services
Policy #:MA09.020j

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

This policy does not apply to radiation therapy treatment requests performed in an inpatient setting or emergent situations.

The Company has delegated the responsibility for utilization management activities for the following radiation therapy services to CareCore National, LLC d/b/a eviCore healthcare (eviCore), for outpatient, non-emergent radiation therapy services. eviCore utilizes Radiation Therapy Clinical Guidelines, available at https://www.evicore.com/resources/Pages/providers.aspx to determine the medical necessity for the following services:
  • External beam including 2D, 3D conformal, intensity-modulated (IMRT), tomotherapy, image-guided radiation therapy (IGRT), stereotactic body radiation therapy (SBRT), and stereotactic radiosurgery (SRS);
  • Proton beam radiation therapy;
  • Brachytherapy including low-dose rate (LDR), high-dose rate (HDR), and outpatient intra-operative techniques (IORT);
  • Hyperthermia;
  • Neutron radiotherapy;
  • Radio-labeled drugs used for radiation therapy (e.g., Radium Ra 223 dichloride (Xofigo®), ibritumomab tiuxetan [Zevalin®], Lutetium; Lu 177 dotatate [Lutathera], iobenguane I-131 [Azedra®])

The use of radiation therapy services, which are listed in this policy, for conditions not addressed in the eviCore Radiation Therapy Clinical Guidelines, may be considered experimental/investigational or not medically necessary, and, therefore, not covered.

REQUIRED DOCUMENTATION

The individual’s medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Policy Guidelines

This policy is consistent with Medicare's coverage criteria. The Company's payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, radiation therapy services are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria for the services are met. However, services that are identified in this policy as experimental/investigational are not eligible for coverage or reimbursement by the Company.

Description

The Company has delegated the responsibility for utilization management activities of radiation therapy services to CareCore National, LLC d/b/a eviCore healthcare (eviCore), to manage requests for outpatient, non-emergent radiation therapy services.

eviCore will utilize its Radiation Therapy Clinical Guidelines to determine the medical necessity for select radiation therapy services, and to direct the application of these services to our members.

eviCore Radiation Therapy Clinical Guidelines are based on evidence-based guidelines and recommendations from national and international medical societies, and evidence-based medicine research centers, including, but not limited to, American Society of Radiation Oncology [ASTRO], National Comprehensive Cancer Network [NCCN], and American College of Radiology [ACR].
References

CareCore National, LLC d/b/a eviCore healthcare. Radiation Therapy Clinical Guidelines. Available at: https://www.evicore.com/resources/Pages/providers.aspx. Accessed September 16, 2019.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

See Attachment A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

See Attachment A


Revenue Code Number(s)

See Attachment A

Coding and Billing Requirements


Cross References

Attachment A: Radiation Therapy Services
Description: CPT, HCPCS and Revenue Codes







Policy History

Revisions from MA09.020j:
01/21/2020eviCore healthcare has revised their Radiation Therapy Clinical Guidelines. These guidelines will become effective 01/21/2020. These guidelines are available online at: https://www.evicore.com/resources/Pages/providers.aspx.

The following HCPCS codes were added to Attachment A of this policy: A4648, A4650, A9517, A9527, A9530, A9563, A9564, A9600, A9604, C1715, C1716, C1717, C1719, C2634, C2635, C2636, C2637, C2638, C2639, C2640, C2641, C2642, C2643, C2644, C2698, C2699, C9725, C9728
________________________________________________________________

Note: On 12/04/2019, Attachment A of this policy was updated with HCPCS coding changes effective 01/01/2020.

Added: A9590
Removed: C9408

Revisions from MA09.020i:
07/01/2019eviCore healthcare has revised their Radiation Therapy Clinical Guidelines. These guidelines will become effective 07/01/2019. These guidelines are available online at: https://www.carecorenational.com/benefits-management/radiation-therapy/radiation-therapy-tools-and-criteria.aspx.

Revisions from MA09.020h:
03/01/2019eviCore healthcare has revised their Radiation Therapy Clinical Guidelines. These guidelines will become effective 03/01/2019. These guidelines are available online at: https://www.carecorenational.com/benefits-management/radiation-therapy/radiation-therapy-tools-and-criteria.aspx.

Iobenguane I-131 [Azedra®] was added to the list of radio-labeled drugs used for radiation therapy that eviCore manages.

Coding:

The following CPT codes were added to Attachment A of this policy: 61796, 61797, 61798, 61799, 61800, 79005, 79403

The following HCPCS codes were added to Attachment A of this policy: A9513, A9543, C2616, C9726

The following HCPCS code was removed from Attachment A of this policy: C9031

The following CPT narrative has been revised in this policy: 77387
________________________________________________________________

Note: On 12/18/2018, Attachment A of this policy was updated with coding changes effective 01/01/2019.

Added: C9408
Removed: 0190T, 0333

As a result of these coding updates, the version of this policy was revised from “g” to “h.”

Revisions from MA09.020g:
01/01/2019This version of the policy will become effective 01/01/2019.

This policy has been identified for the CPT/HCPCS code update, effective 01/01/2019.

The following CPT codes were added to Attachment A of this policy: 61796, 61797, 61798, 61799, 61800, 79005, 79403

The following HCPCS codes were added to Attachment A of this policy: A9513, A9543, C2616, C9408, C9726

The following CPT code was termed and removed from Attachment A of this policy: 0190T

The following HCPCS code was termed and removed from Attachment A of this policy: C9031

The following Revenue code was removed from Attachment A of this policy: 0333

The following CPT narrative has been revised in Attachment A of this policy: 77387

Revisions from MA09.020f:
10/01/2018This version of the policy will become effective 10/01/2018..

eviCore healthcare has revised their Radiation Therapy Clinical Guidelines. These guidelines will become effective 10/01/2018. Upon approval, these guidelines will be available online at: https://www.carecorenational.com/benefits-management/radiation-therapy/radiation-therapy-tools-and-criteria.aspx.

All references to Precertification/Preapproval have been removed from this policy.

The following HCPCS code was removed from Attachment A of this policy: S8030

The following codes used to report Lutathera (Lutetium; Lu 177 dotatate) were added to Attachment A of this policy: 79101, C9031.

Guidelines and utilization management for Lutathera (Lutetium; Lu 177 dotatate) through eviCore healthcare will become effective 07/01/2018.

Revisions from MA09.020e:
01/01/2018This policy has been identified for the CPT code update, effective 01/01/2018.

The following CPT code has been added to Attachment A of this policy: 19294

The following CPT code has been removed from Attachment A of this policy: 77422

Revisions from MA09.020d:
09/01/2017Independence Blue Cross (Independence) delegates precertification of non-emergent outpatient radiation therapy services for all Medicare Advantage HMO, POS, and PPO members to CareCore National, LLC d/b/a eviCore healthcare (eviCore), an independent company. eviCore maintains Radiation Therapy Clinical Guidelines for Independence that contain medical necessity criteria used during the precertification process for our members.

Effective September 1, 2017, Independence will update its Radiation Treatment of Breast Carcinoma guideline to indicate that a hypofractionated regimen is the preferred treatment for patients with early stage (T1-2N0) breast carcinoma who meet certain criteria. For these patients, a request for precertification of conventional fractionation will require a peer-to-peer call with an eviCore Radiation Oncologist.

The Independence Blue Cross Radiation Therapy Clinical Guidelines – FUTURE - Effective 9/1/2017 are available for review on eviCore’s website (https://www.evicore.com/ReferenceGuidelines/IBC%20Radiation%20Therapy%20Criteria_V1.0.2017_Effective%2009.01.2017.pdf). These guidelines include the updated criteria for treatment of breast carcinoma using hypofractionated radiation therapy.

Revisions from MA09.020c:
01/01/2017This version of the policy will become effective 01/01/2017.

Revisions from MA09.020b:
09/02/2016The policy has been reviewed and reissued to communicate the Company’s continuing delegation of precertification/preapproval of radiation therapy services to CareCore National, LLC d/b/a eviCore healthcare (eviCore) for outpatient, non-emergent radiation therapy services.

eviCore healthcare has revised their Radiation Therapy Guidelines. These guidelines will become effective September 2, 2016. Upon approval, these guidelines will be available online at: https://www.carecorenational.com/benefits-management/radiation-therapy/radiation-therapy-tools-and-criteria.aspx.

Furthermore, effective September 2, 2016, eviCore healthcare's guidelines will be utilized for the management of Radium Ra 223 dichloride (Xofigo®) Injections.
01/1/2016This policy was reviewed and updated to communicate Company's continued position on Radiation Therapy Services. On 12/30/2016 Attachment A was updated with coding changes.

Revisions from MA09.020a:
08/19/2015This policy was reviewed and reissued in accordance with the Company's Policy Confirmation Review track. CareCore National LLC/ CareCore was changed to CareCore National, LLC d/b/a eviCore healthcare (eviCore) throughout the document. Link to the guidelines was updated.
05/01/2015Policy #MA09.020a updated to communicate the Company is delegating precertification/preapproval of additional radiation therapy services to CareCore National, LLC (CareCore) for outpatient, non-emergent radiation therapy services. Policy #MA09.020a also supersedes MA08.069, MA08.014, MA09.007

Revisions from MA09.020:
01/01/2015New medical policy MA09.020 issued to communicate the Company is delegating precertification/preapproval of radiation therapy services to CareCore National, LLC (CareCore) for outpatient, non-emergent radiation therapy services.





Version Effective Date: 01/21/2020
Version Issued Date: 01/21/2020
Version Reissued Date: N/A