Notification

Radiation Therapy Services (Independence)


Notification Issue Date: 11/30/2018

This version of the policy will become effective 03/01/2019.

eviCore 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.”



Medical Policy Bulletin


Title:Radiation Therapy Services (Independence)

Policy #:09.00.56h

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


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. 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.

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 Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions and limitations of the member’s contract.

This policy does not apply to self-funded groups for whom eviCore's Radiation Therapy Services program is not applicable; individual benefits must be verified.

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.carecorenational.com/benefits-management/radiation-therapy/radiation-therapy-tools-and-criteria.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.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, radiation therapy services are covered under the medical benefits of the Company’s products when the medical necessity criteria for the services are met. However, services that are identified as experimental/investigational or not medically necessary are not eligible for coverage or reimbursement by the company.

The CareCore National, LLC d/b/a eviCore healthcare (eviCore) Radiation Therapy Clinical Guideline algorithms will not be applied for those self-funded groups for whom eviCore's Radiation Therapy Services program is not applicable. Individual benefits must be verified.

Description

CareCore National, LLC d/b/a eviCore healthcare (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 Tools and Criteria. Available at: https://www.carecorenational.com/benefits-management/radiation-therapy/radiation-therapy-tools-and-criteria.aspx. Accessed November 6, 2018.



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 (Independence)
Description: CPT, HCPCS and Revenue Codes




Policy History

Revisions from 09.00.56h:
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 09.00.56g:
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 09.00.56f:
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.

Language was added stating that this policy does not apply to self-funded groups for whom eviCore's Radiation Therapy Services program is not applicable.

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 09.00.56e:
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


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 03/01/2019
Version Issued Date: 03/01/2019
Version Reissued Date: N/A

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