Medical Policy


Subject:  Brachytherapy for Oncologic Indications
Policy #:  RAD.00014Current Effective Date:  05/19/2014
Status:RevisedLast Review Date:  05/15/2014

Description/Scope

Brachytherapy is a form of radiation treatment used to stop the growth of cancer cells and involves placing radioactive material directly into or near a tumor, which allows the tumor to receive a dose of radiation while reducing the exposure to surrounding tissue. Treatment time varies, depending upon the method of treatment, the type of radioactive material, and the cancer site.

Note: Please see the following documents for additional information:

Position Statement

Medically Necessary:

Brachytherapy is considered medically necessary for any of the following (1-10) indications:

  1. Breast cancer
    1. As an adjunctive "boost" to the tumor bed in individuals who have received whole breast radiation therapy after prior breast conserving surgery (i.e., lumpectomy); or
    2. As a technique of partial breast irradiation (for example, multi-catheter interstitial or balloon) as an alternative to whole breast irradiation in individuals who meet ALL of the following criteria:
      1. Tumor removed with breast conserving surgery (for example lumpectomy) with resected margins free of tumor; and
      2. Stage 0, I or II disease (Stage II tumors must be less than or equal to 3 cm in diameter); and
      3. Node negative; and
      4. Individual's age is greater than or equal to 50 years.
  2. Cholangiocarcinoma – as secondary or adjuvant treatment for individuals who meet any of the following criteria:
    1. Resected with positive margin (R1); or
    2. Resected gross residual disease (R2); or
    3. Carcinoma in situ at margin; or
    4. Positive regional nodes.
  3. Esophageal cancer, to treat unresectable tumors and as palliative treatment for obstructing tumors
  4. Head and neck cancers- including lip, tongue, floor of mouth, tonsil, pharynx, nasopharynx, sinuses and neck cancers
  5. Gynecologic cancers: (Uterine, cervical, endometrial or vulvar/vaginal cancer)
  6. Lung cancer:
    1. Endobronchial treatment of primary bronchial tumors that cannot be excised surgically or cannot be treated by external beam radiation therapy (EBRT); or
    2. Palliative treatment for obstructing primary or metastatic endobronchial tumors.
  7. Ocular brachytherapy for choroidal melanoma and retinoblastoma when ALL of the following criteria are met:
    1. Apical height of the tumor is 2.5 to 10.0 mm; and
    2. Maximum basal tumor diameter of 18.0 mm or less; and
    3. For choroidal melanoma, unilateral disease has been confirmed.
  8. Penile cancer when the following criteria are met:
    1. Squamous cell carcinoma confined to the glans or prepuce; and
    2. Tumor size is less than or equal to 4 cm; and
    3. Inguinal lymph nodes are negative (N0) or are unable to be assessed (NX).
  9. Prostate cancer that is clinically localized when one of the following criteria are met:
    1. Individual with low-risk of recurrence which is defined as tumor stage T1-T2a, low Gleason score ([GS] less than or equal to 6), serum prostate specific antigen (PSA) level below 10 ng/mL, and greater than or equal to 10 year expected survival and treatment involves:
      1. Permanent low dose rate [LDR] brachytherapy as monotherapy.
    2. Individual with intermediate-risk of recurrence which is defined as tumor stage any T2b to T2c, or GS of 7, or PSA value of 10-20 ng/mL, and treatment involves one of the following:
      1. LDR brachytherapy with or without EBRT; or
      2. HDR brachytherapy with or without EBRT.
    3. Individual with high-risk of recurrence which is defined as stage T3a or GS 8-10, or PSA level greater than 20 ng/mL, and treatment involves one of the following:
      1. LDR brachytherapy in combination with EBRT; or
      2. HDR brachytherapy in combination with EBRT.
  10. Soft tissue sarcoma with positive margins or margins less than 5 mm.

Investigational and Not Medically Necessary:

Brachytherapy is considered investigational and not medically necessary in individuals not meeting the above criteria.

Endobronchial brachytherapy is considered investigational and not medically necessary as a 'boost' for EBRT.

The use of high dose rate electronic brachytherapy is considered investigational and not medically necessary for all indications, including but not limited to the treatment of breast cancer.

Rationale

Breast Cancer
Breast brachytherapy as a "boost" to whole breast irradiation is an accepted technique for women who have undergone breast conserving surgery and may have a have a higher risk of local failure. The "boost" brachytherapy provides higher radiation doses to the lumpectomy site in conjunction with whole breast irradiation.

Partial breast irradiation using breast brachytherapy after breast conserving surgery has been emerging as an alternative to whole breast irradiation. This option is based on the observation that for appropriately selected individuals, irradiation of the whole breast is not necessary. For example, randomized trials comparing lumpectomy alone versus lumpectomy followed by whole breast irradiation do not show a significant difference in the rate of tumor recurrence outside of the tumor bed. These findings suggest that the benefit of irradiation in general is related to the decreased risk of tumor recurrence in the tumor bed alone, the tissue at highest risk of a local recurrence. A number of clinical studies of partial breast irradiation in conjunction with lumpectomy demonstrate five year local recurrence rates of 0.0%-4.7%, which is comparable to external beam radiation (Benitez, 2004; Keisch, 2003; King, 2000; Polgar, 2002; Polgar, 2007; Vicini, 2003). Partial breast irradiation using brachytherapy is also associated with good to excellent cosmetic outcomes with minimal treatment times, compared to the 6-7 week course of whole breast irradiation. 

Methods of providing partial breast irradiation include multiple interstitial catheters, or devices placed directly into the lumpectomy cavity and afterloaded with radioactive material. Examples of devices include Mammosite® RTS (Hologic Inc., Marlborough, MA), SenoRad Multi-Lumen Balloon Source Applicator for Brachytherapy (SenoRx, Irvine, CA) and Savi™ (Cianna, Aliso Viejo, CA).

In the Mammosite registry trial (Zannis, 2005), three different techniques were utilized to insert the brachytherapy balloon catheter (1) at the time of lumpectomy into an open cavity (2) after surgery with ultrasound guidance through a separate small lateral incision into a closed cavity (US/lat), or (3) after surgery by entering directly through the lumpectomy wound (scar entry technique). As of November 2004, data on 1403 individuals with balloon implantation were entered into the registry. Balloon catheter placement at the time of lumpectomy occurred in 619 (44%) individuals, after surgery with ultrasound guidance in 576 (41%) and with the scar entry technique (SET method) in 197 (14%) individuals. As the study progressed, there was a trend toward increased use in the postoperative techniques. Of these, a total of 1280 (91%) received brachytherapy and 1237 (87%) of the implanted (non-boost) individuals made up the study population. Catheters were explanted in 123 (9%) prematurely and did not receive brachytherapy (open cavity, 10%; US/lat, 6%; and SET, 10%). All of the explantations due to disqualifying pathology (tumor size greater than 2 cm, positive margins, lobular histology, EIC and positive nodes) were accounted for cases where the open-cavity technique was utilized to place the balloon. There was a statistically difference in the median length of time from device placement to initiation of brachytherapy among the three techniques, but the authors felt it appeared to be clinically insignificant. There was no statistically significant difference in cosmesis between the three insertion techniques with at least 12 month follow-up (open cavity ,93%; US/lat, 92%; and SET 93%, P=.4784). The authors noted a limitation of the study involved enrollment into the registry before, during or after brachytherapy, which limited the catheter explantation analysis (i.e., individuals may have had catheters removed and not enrolled into the registry). Therefore, the authors concluded "a postoperative timing of placement, as with the US/lat or SET techniques permits more careful selection of patients who have pathologically appropriate cancers, decreasing the incidence of premature explantation of the catheter because of disqualifying pathology" (Zannis, 2005).

Currently, there are ongoing randomized phase III studies of accelerated partial breast irradiation (APBI) with brachytherapy to confirm the results of initial phase II studies suggesting that the local control rates of partial and whole breast irradiation (WBI) are equivalent (University of Wisconsin, 2005). However, at the same time, the American Brachytherapy Society and the American Society of Breast Surgeons (ASBrS) have published recommendations regarding selection criteria for breast brachytherapy, indicating the general acceptance of brachytherapy as an alternative to whole breast irradiation (ASBrS, 2008; Arthur, 2003). This position indicates that partial breast irradiation with breast brachytherapy is considered medical necessary in certain individuals and reflects the general acceptance of these techniques among the medical community. The selection criteria in this document are similar to the selection criteria included in the large randomized study of breast brachytherapy sponsored by the National Cancer Institute (University of Wisconsin, 2005) and recommended inclusion criteria from the American Brachytherapy Society Breast Brachytherapy Task Group (2007).

In 2010, recommendations for selection criteria for accelerated partial breast irradiation were provided by the Groupe Europeen de Curietherapie-European Society for Therapeutic Radiology and Oncology ([GEC-ESTRO], Polgar, 2010). The reviewers noted conflicting results for partial breast irradiation for women between ages 41 and 50 years, and further prospective trials are needed to determine the safety and efficacy for these women. Therefore, the authors recommend women below the age of 40 years should not be treated with accelerated partial breast irradiation. In addition, based on published data and the high risk of fat necrosis with large tumors (greater than 3 cm) and the large volume of implants required to adequately treat large tumors, the authors do not recommend APBI therapy for large tumors (T3 or T4). Polgar and colleagues acknowledged long-term data from prospective studies are needed to support the use of APBI for low-risk ductal carcinoma insitu (DCIS) as many of the published trials had excluded individuals with DCIS. Positive lymph node status portends a higher risk of local recurrence and development of distant metastases. Thus, the authors noted, "it seems to be safe not to treat patients with involved axillary lymph nodes with APBI outside the context of prospective clinical trials."

Nelson and colleagues (2009) reported 4-year data from an ongoing registry trial collecting data on 1,440 individuals with 1,449 breasts treated with the Mammosite device. Invasive cancers with a median tumor size of 10 mm were treated in 1,255 breasts, and 194 breasts had ductal carcinoma with a median size of 8 mm. The median follow-up for the entire cohort was 36.1 months, while the median follow-up was 44.3 months for the first 400 treated breasts. Ipsilateral breast tumor recurrence (IBTR) developed in 28 individuals (1.9%) with a 3-year actuarial rate of 2.15%. Recurrence occurred in 10 individuals. The 3-year actuarial rate for true recurrence/marginal miss was 0.72%, elsewhere recurrence was 1.44% and axillary recurrence was 0.36%. The overall survival rate for the entire group was 95.6%. In the cohort of the initial 400 individuals with longer median follow-up, the 4-year actuarial rate of IBTR was 2.65%. The 4-year actuarial rate for true recurrence/marginal miss was 0.33%, elsewhere recurrence was 2.32% and axillary recurrence was 0.6%. The 4-year actuarial overall survival rate was 94%. Description of appearances reported as good or excellent were 95% at 12 months and 91% at 48 months. Adverse events included seromas 26.8%, with most seromas occurring during the first 12 months and more frequently with the open implant placement. Infectious complications occurred in 11.5% of participants. Fat necrosis was reported in 2% of individuals. The authors noted the IBTR rates were comparable to 4% in-breast failure rate reported in a group of individuals treated with multicatheter brachytherapy.

A consensus statement about accelerated partial breast irradiation (APBI) outside of the clinical trial context was developed by a Task Force for the American Society for Radiation Oncology ([ASTRO]; Smith, 2009). The published literature was reviewed and 4 randomized trials and 38 prospective single-arm studies were analyzed. The data was insufficient to identify a subset of individuals at very low-risk of occult disease. Therefore, the Task Force used the available evidence, inclusion criteria and the specific clinical characteristics of participants in the prospective trials to determine the selection criteria used in the "suitable" group. The "cautionary" group included study participants when the Task Force had uncertainty about the appropriateness of APBI. The "unsuitable" group was based on the paucity of clinical trial evidence to support the use of APBI. Factors included in the "suitable" group are T1 tumors (less than or equal to 2 cm); negative tumor margins; and node status of pN0 (i-, i+). The "cautionary" group included T0 or T2 tumors (2.1 to 3.0 cm) and close (less than 2 mm) tumor margins. The factors included in the "unsuitable" group were T3 or T4 tumors (greater than 3 cm); positive tumor margins and node status of pN1 – pN3. The Task Group was not able to determine the optimal technique for APBI delivery as there is insufficient clinical and dosimeteric data. Additionally, the long-term effectiveness data was available for interstitial brachytherapy (average 5.4 years), but the average follow-up for balloon brachytherapy was 2.3 years and intraoperative brachytherapy was 2.1 years. There are ongoing clinical trials comparing the safety and effectiveness of APBI and whole breast irradiation.

A pooled analysis of 300 women with DCIS treated with APBI was retrospectively analyzed and reported by Vicini and colleagues (2013). Data was prospectively entered into the ASBrS Mammosite Registry and the database for William Beaumont Hospital (WBH). Individuals with DCIS were compared against pooled data for invasive suitable risk group (n=653) and invasive suitable/cautionary risk group (n=1,298). At 5 years the ipsilateral breast tumor recurrence (IBTR) for all individuals with DCIS was 2.6% without regional recurrence (RR). The rate of distant metastases (DM) was 0.4% with a 5-year DFS and OS of 97.4% and 96.4% respectively. A subset of the DCIS group included 201 individuals with tumors less than or equal to 3 cm with no other unsuitable risk factor. The cautionary DCIS group did not differ significantly in IBTR compared to the invasive suitable/cautionary group (2.6% vs. 3.1%, P=0.90). There were significant improvements in DM (0 vs. 2.5%, P=0.05), DFS (98.5% vs. 94.4%, P=0.05) and OS (95.7vs. 90.8%, P=0.03) for the individuals with cautionary DCIS. There was no difference in IBTR when comparing cautionary DCIS to invasive suitable individuals (2.6% vs. 2.4%, P=0.76), with OS was improved for the DCIS cohort 95.7% vs. 90.9%, P=0.02). The authors concluded the pooled data demonstrates APBI can provide low rates of IBTR in individuals with low-risk DCIS. The limitations noted pooled data between the DCIS subgroups did not provide "definitive conclusions." Additional study of DCIS is warranted for determining if DCIS remains in the cautionary grouping for the ASTRO consensus panel.

Concerns with the long-term safety and efficacy of brachytherapy as a form of APBI continue while data from ongoing trials are collected. Smith and colleagues (2012) reported data from a retrospective population study of women 67 years and older who were in the Medicare fee-for-service data set. A total of 92,735 individuals diagnosed with invasive breast cancer and treated with breast brachytherapy or whole breast irradiation (WBI) were eligible for analysis. With a median follow-up of 3.03 years, the investigators noted a higher risk of subsequent mastectomy with breast brachytherapy, with a 5-year cumulative incidence of 3.95% (95% CI, 3.19% - 4.88%) compared to 2.18% (95% CI, 2.04% – 2.33%; P < 0.001) in individuals treated with WBI. There were higher risks of infectious and noninfectious postoperative complications associated with brachytherapy 27.56% (1,916 of 6,952 individuals; 95% CI, 26.51% - 28.63%) compared to 16.92% (14,518 of 85,783 individuals; 95% CI, 16.67% - 17.18%) (P<.0001) treated with WBI within one year of lumpectomy. There was a significant difference (P < 0.001) in the 5-year cumulative incidence of breast pain in individuals treated with brachytherapy 14.55% compared to 11.92% in individuals who received WBI. The 5-year rate for fat necrosis was also higher in the brachytherapy group (8.26%) compared to 4.05% in the WBI group (P < 0.001). The 5-year incidence of pneumonitis was lower for individuals treated with WBI (0.12%) versus those treated with brachytherapy (0.72%; P < 0.001). The authors noted in this analysis of older women with breast cancer, there was a significant risk of subsequent mastectomy in individuals treated with brachytherapy compared to women treated with WBI. The validity and the ability to determine if the effects can be generalized to younger women will need to be confirmed in additional study. There is an ongoing RTOG 0413/NSABP B-39 randomized trial that is accruing participants to WBI vs. partial breast irradiation with brachytherapy or external beam radiation (Smith, 2012).

The National Comprehensive Cancer Network® (NCCN, 2014) guideline lists brachytherapy treatment for breast cancer as a "boost" with whole breast radiation therapy and as a method to provide APBI. NCCN recommends treatment with APBI to be provided in a prospective clinical trial when possible. If APBI is provided off trial, then brachytherapy is recommended for those with a low risk of recurrence. Based on the American Society for Radiation Oncology (ASTRO) recommendations, women 60 years and older who are negative for the BRCA 1 and 2 mutations, and with negative tumor margins would be suitable candidates for APBI with brachytherapy.

Cholangiocarcinoma
Cholangiocarcinoma (intrahepatic and extraphepatic) is a rare malignancy that develops from the epithelial cells lining the bile ducts and accounts for approximately 3% of all gastrointestinal cancers (Shinohara, 2009). In a retrospective review of the data of individuals with cholangiocarcinoma in the Surveillance, Epidemiology and End Results (SEER) database, Shinohara and colleagues (2009) reviewed a total of 9,704 individuals with extrahepatic (EHC) or intrahepatic (IHC) carcinomas. Forty-three of theses individuals received brachytherapy alone while 150 individuals received a combination treatment of external-beam radiation therapy (EBRT) and brachytherapy. A comparison group of 6,859 individuals were not treated with any radiation therapy. Median survival was significantly longer at 11 months for those treated with brachytherapy (95% confidence interval [CI], 9-13 months) versus 4 months (P< 0.0001) for those who did not receive any radiation therapy. According to the National Cancer Institute (2010), extrahepatic bile duct cancer is curable by surgery in less than 10% of all cases. Palliative measures with brachytherapy or stents allow biliary drainage and improved survival. In addition, specialty consensus opinion recommends the use of brachytherapy as a treatment of cholangiocarcinoma.

Esophageal cancer
Frobe and colleagues (2009) reported on a series of 30 individuals treated with intraluminal high-dose rate brachtherapy (ILHDR BT) as palliative therapy for squamous cell carcinoma of the esophagus. Twenty-nine participants received two sessions of ILHDR BT within a week, and one person received one treatment. Eight individuals received additional EBRT. Two individuals required dilations and one had a stent placement for worsening dysphagia. Overall quality of life (QOL) was assessed, and a statistically significant improvement was noted for dysphagia (P < 0.006). Other improvements were also noted in ability to eat (P = 0.02), sleeping (P = 0.032) and social life (P = 0.002). One person died from distant metastasis and a 165 day median overall survival (95% CI 128-195 days) from death of any cause was noted. The authors noted the subset of eight individuals who received combined ILHDRBT and EBRT was too small to show a statistical difference between the treatments.

In a prospective randomized trial Guo (2008) compared intraluminal brachytherapy stents with iodine 125 (I125) versus conventional self- expandable covered stents in individuals with advanced esophageal cancer. Although all 53 participants had significant improvement of dysphagia at one month, the 27 individuals in the treatment group had improved significantly better than the control group at two months (P < 0.05). Adverse events included hemorrhage in both groups with a combined occurrence rate of 30% (16 individuals). There was a significant difference (P < 0.001) in the median and mean survival times in the irradiation stent cohort compared to the control group. The irradiation stent group had a median survival of 7 months (95% CI) with a mean of 8.3 months, versus a median survival of 4 months (CI 95% CI) in the control group, with a mean of 3.5 months.

Head and Neck Carcinoma
Brachytherapy is usually provided in conjunction with moderate doses of external beam radiation therapy (EBRT). A literature review and expert panel consensus resulted in the American Brachytherapy Society (Nag, 2001) recommendation to include high dose rate (HDR) brachytherapy as a treatment option for head and neck carcinomas based on the extrapolation of low-dose rate (LDR) brachytherapy. The authors recognized the paucity of literature for HDR brachytherapy use in head and neck cancers as well as the concerns of radiation safety. LDR brachytherapy has been used for head and neck cancers, including lip, tongue, floor of mouth, tonsil, pharynx, nasopharynx, sinuses and neck. The panel was unable to come to unanimous consensus on the sequencing of EBRT and brachytherapy.

Combined practice guidelines (Erickson, 2011) by the American Society for Radiation Oncology (ASTRO) and American College of Radiology (ACR) in cooperation with the American Brachytherapy Society (ABS) include recommendations for high-dose-rate brachytherapy treatment for head and neck cancers. The guidelines note the same "operative techniques may be used for HDR brachytherapy" as LDR brachytherapy.

Lung Tumors
There are two categories of individuals who may be considered candidates for endobronchial brachytherapy.

Primary endobronchial treatment
Candidates for primary treatment have principally included individuals with early-stage endobronchial tumors who are not otherwise considered candidates for surgical resection or external beam radiation due to co-morbidities or location of the tumor. Results have predominantly been reported in case series where complete response rates in the range of 60%–80% have been noted (Perol, 1997; Raben, 1997). The indications and outcomes of brachytherapy as primary therapy are comparable to those reported for photodynamic therapy.

Palliative endobronchial treatment
Many individuals with non-small cell carcinoma are initially treated with external beam radiation therapy but ultimately experience local recurrence. Unfortunately, many individuals are not candidates for further external beam radiation therapy due to the limited tolerance of normal tissue. Therefore, endobronchial brachytherapy has been explored as an alternative. Resolution of symptoms short-term, such as hemoptysis, cough, dyspnea and resolution of obstructive atelectasis or pneumonitis are appropriate for palliative therapy. In a summary of studies of palliative endobronchial brachytherapy between 1985 and 1994, Villanueva and colleagues reported effective palliation in 60%–100% of individuals (Villanueva, 1995). The median survival of these individuals is typically less than 9 months. No randomized controlled study has shown that endobronchial brachytherapy improves survival rate.

There have been no comparative trials of palliative or primary treatment comparing different methods of local control (i.e., endobronchial brachytherapy, photodynamic therapy, laser therapy, microwave or cryotherapy) to determine if any one method is superior to another in different subsets of individuals or if combinations of therapy provide improved results. The choice of modality may depend on local availability and expertise.

Brachytherapy has also been investigated as a technique to deliver a "boost" to individuals undergoing primary EBRT. External beam radiation therapy is typically the primary treatment for the majority of individuals with non-small cell lung carcinoma (NSCLC) who usually present with surgically unresectable disease and NSCLC is unresponsive to chemotherapy. Huber and colleagues (1997) reported on the results of a trial that randomized 98 individuals with inoperable lung cancer to receive either external beam radiotherapy or endobronchial brachytherapy. While the brachytherapy group experienced a longer period of local control, there was no significant difference in survival between the two groups.

Ocular Cancers
Choroidal Melanoma
Choroidal melanoma is the most common type of primary intraocular melanoma, but it is fairly rare. Information to determine treatment plans includes the stage of the disease, tumor size and proximity to other eye structures. Enucleation is performed for small and large tumors, primarily when vision loss is anticipated as a result of other treatment modalities (American Cancer Society, 2011).

The Collaborative Ocular Melanoma Study Group (COMS, 2006) studied enucleation versus brachytherapy in a multicenter randomized trial enrolling 1,317 individuals. Within the first 5 years, 252 participants died with 19% (127) in the enucleation group versus 19% (125) in the brachytherapy group. At 5 years, there was no significant difference in the mortality rate from all causes with 19% in the enucleation cohort compared to 18% in the brachytherapy group. Data on 1,263 of the participants was assessable for the first 5 years and 799 participants at 10 years. During the 12 years after enrollment, the cumulative rates of death by histopathologically confirmed metastasis and other causes were similar. Pooled data on all-cause mortality at 5 years was 19% and 35% at 10 years. Histopathologically confirmed melanoma metastasis did not differ in cumulative rates of death by treatment assignment. Pooled data on histopathologically confirmed mortality was 10% and 17% at 5- and 10-years, respectively. Forty-five percent of all individuals treated by either brachytherapy or enucleation were alive and disease free at the 12 year follow-up.

Melia and Colleagues (2006) reported results of a 5-year quality of life study on 209 participants randomized to either enucleation or brachytherapy treatment. Visual function (i.e., driving, peripheral vision) was reported to be significantly better in the brachytherapy cohort compared to the enucleation group for up to 2 years following treatment. In both groups, anxiety levels were decreased significantly after treatment, but later resolution of anxiety was reported less in the brachytherapy group. The authors suggested the ongoing anxiety in the brachytherapy group might have been a result of uncertainty with unknown survival benefits between the treatment modalities.

Retinoblastoma
According to the NCI (2013), retinoblastoma is a relatively uncommon cancer affecting the eye in 3% of cancers occurring in children less than 15 years old, and 95% of the cases occur before the age of 5 years. A heritable form of retinoblastoma may present as unilateral or bilateral disease. Retinoblastoma is frequently confined to the eye in 90% of the cases, and can be successfully treated with local therapies. The goals for treatment include preservation of the eye, prevention of blindness and improved overall survival and quality of life. Treatment options include enucleation, external beam radiation, photocoagulation, chemotherapy and brachytherapy. A nonrandomized, assignment trial is currently recruiting participants. 

In a retrospective analysis, Shields and colleagues (2006) reviewed the records of children treated with plaque radiotherapy (I125) for retinoblastoma recurring after prior therapy with chemoreduction (CRD) or CRD with external beam radiation therapy (EBRT). The cohort consisted of 64 children with 84 retinoblastomas in 71 eyes. Mean tumor size was 9 mm in basal dimension (range 3 -18 mm) and 4 mm in thickness (range 1 – 8 mm). At a median follow-up of 4 years, plaque brachytherapy provided complete tumor control for 81 (95%) tumors. Recurrence occurred at a mean of 6 months in 3 eyes. Complications at 5-years by Kaplan-Meier analysis included transient mild vitreous hemorrhage (54%), cataract (43%), nonproliferative maculopathy (24%), proliferative retinopathy (19%), papillopathy (16%), iris neovascularization (8%) and glaucoma (4%).

Penile Cancer
According to the National Cancer Institute (NCI, 2012) penile cancer is rare in developed countries. Treatment includes surgical excision of the lesion which may include a partial or total penectomy. De Crevoisier (2009) and colleagues treated 144 inguinal node-negative men with squamous cell carcinoma (SCC) of the penile glans or prepuce with brachytherapy. The median tumor diameter was 20 mm (range 2-50). Needles loaded with Iridium-192 lines were inserted into the penis at equal distances with a medium number of six lines placed. Participants were assessed every 4 months for 2 years and then every 6 months thereafter. The median follow-up was 5.7 years. Local recurrence occurred in 21(17%) of the participants with a median of 1.8 years to penile recurrence. Salvage treatment included partial penectomy (n=12), total penectomy (n=6), repeat brachytherapy for 2 individuals, and 1 participant had local excision. Complications included a 10-year stenosis rate of 29% and a 10-year painful ulceration rate of 26%. The 10-year cancer-specific and overall survival rates were 92% (CI 95% 87-97) and 65%, (CI 95%, 56-74) respectively. The 10-year recurrence-free rate was 78% (CI 95%, 70-86) and the 10-year probability for avoidance of penile surgery related to complications or recurrence was 72% (CI 95%, 62-82). After multivariate analysis, the authors noted the tumor diameter greater than 4 cm had a significantly increased risk of recurrence (p= 0.02).

Prostate Cancer
Treatment options for clinically localized prostate cancer include surgery, brachytherapy and watchful waiting. Randomized studies of these options have been very difficult to conduct due to prolonged natural history of prostate cancer and the many variables of individual prostate cancer, such as levels of prostate specific antigen (PSA), tumor size and tumor grade (i.e., Gleason score). However, LDR brachytherapy using permanently implanted seeds is a well accepted treatment option for clinically localized prostate cancer. The American College of Radiology (ACR) and the American Society for Therapeutic Radiation and Oncology (ASTRO) practice guideline (2010) for transperineal LDR brachytherapy notes individuals "With a significant risk of disease outside of the implant volume may benefit from the addition of external beam irradiation and/or total hormonal ablation."

Lawton and colleagues (2012) reported long-term results from a phase 2 trial of EBRT combined with permanent LDR brachytherapy for intermediate-risk, localized prostate cancer. The multi-center trial enrolled 138 participants with intermediate-risk prostate cancer, and 131 men were treated and eligible for assessment of the primary endpoints, which were rate of acute and late grade 3-5 gastrointestinal (GI) and genitourinary (GU) toxicities. The median follow-up was 8.2 years (range 1.1-9.3). Acute toxicity was defined as an occurrence ≤9 months. There was no grade 4 or 5 acute toxicity. The most common grade 3 GU toxicities included urinary frequency, retention and dysuria. Acute grade 3 sexual dysfunction occurred in 13 (22%) of the 60 men, who had no sexual dysfunction at baseline. The 8-year estimate of late grade ≥3 GU/GI toxicity was 15%. Grade 3 proctitis (n=4), and late grade 3 bladder or GU toxicity (n=13) involving frequency, dysuria, hematuria, and incontinence were noted. There were 2 participants with grade 4 GU toxicity involving necrosis, and there were no late grade 4 GI toxicities. The estimated late grade 3 rate of erectile dysfunction was 42% at 8 years. The 8-year rate of biochemical failure was 18% by the Phoenix definition. The OS and disease-specific survival was 81% and 98%, respectively. The authors concluded combination EBRT and LDR brachytherapy provided durable biochemical control, but late toxicities were reported.  Further study is needed to limit exposure to normal structures to minimize toxicities.

Long-term outcomes on 1,656 consecutive participants treated with permanent interstitial brachytherapy at a single institution had a median follow-up of 7 years. At 12 years, results for the entire cohort were 95.6% biochemical PFS (bPFS), 98.2% cause-specific survival (CSS), and OS was 72.6%. Stratification of cohorts by low-risk cohort included 575 individuals, the intermediate-risk group included 608 men and 473 individuals were high-risk. Analysis based on low-, intermediate- and high-risk disease, respectively, at 12 years were bPFS 98.6%, 96.5% and 90.5%. CSS was 99.8%, 99.3%, and 95.2% and OS was 77.5%, 71.1%, and 69.2% for men with low-, intermediate- and high-risk disease, respectively. The authors concluded permanent interstitial brachytherapy had excellent long-term outcomes in all risk categories (Taira, 2010).

HDR or temporary brachytherapy is a treatment option, which has been primarily investigated as an adjunct to external beam radiation therapy (i.e., three dimensional conformal radiation therapy [3D-CRT], intensity modulated radiation therapy [IMRT], and image guided radiation therapy [IGRT]) in individuals with poor prognostic factors. Several large case series have been reported. Martinez and colleagues (2003) reported on the outcomes of a series of 207 individuals treated between 1991 and 2000. All participants had poor prognostic factors, which included tumor stage T2B, a Gleason score of 7, or a PSA greater than 10 nl/mL. External beam radiation therapy was alternated with HDR radiation therapy as a boost. At a mean follow-up of 4.7 years, overall biochemical control rate (as indicated by PSA monitoring) was 74%, but was 85% if one poor prognostic factor was present, 75% if 2 factors were present, and 50% if all 3 factors were present. Late toxicity was minimal. The authors suggest that these results are similar to or better than other treatment alternatives for prostate cancer with poor prognostic features. In another analysis, the authors performed a matched-pair analysis of HDR brachytherapy boost versus EBRT alone (Kestin, 2000). A total of 161 participants received an HDR boost; they were randomly matched with a unique individual who received EBRT alone. Participants were matched according to PSA level, Gleason score, T stage, and duration of follow-up. Those who received the HDR boost reported a 5-year biochemical control rate of 67% compared to 44% in those receiving EBRT alone. In a review article, Vicini and colleagues (2003) summarized the experience reported in 8 other case series of locally advanced prostate cancer totaling just over 1,000 participants. The biochemical control rate ranged from 74% to 97% with median follow-ups ranging from 11 to 74 months. An international group of investigators reported on the use of HDR as an adjunct to EBRT with or without androgen-deprivation therapy in a case series of 611 participants (Galale, 2004). A total of 209 individuals were treated at William Beaumont Hospital, and thus it is likely that there are overlapping participants with the studies reviewed above. The authors reported that adjunctive HDR was associated with excellent long-term outcomes in terms of biochemical control, disease-free survival and cause-specific survival.

Hoskins and colleagues (2007) reported results from a phase III randomized trial that compared EBRT monotherapy with a dose escalated schedule using high-dose rate brachytherapy. Participants were assigned to receive either standard radiotherapy 55 Gy in 20 fractions five days per week over 4 weeks, or a combined treatment schedule of EBRT followed by HDR brachytherapy. Two hundred twenty participants were randomized with stratification according to T-stage, PSA and Gleason score. Biochemical relapse-free survival was the primary end point and secondary endpoints included overall and relapse-free survival. Participants were treated by two specialists at a single institution. The characteristics of participants were well balanced between the cohorts. A significant improvement (P=0.03) in actuarial biochemical relapse-free survival was reported in the combined HDR treatment group at a median follow-up of 30 months (range 3–91). Mean PSA relapse-free survival in the treatment arm was 5.1 years (95% confidence interval [CI] 4.6–5.5 years) compared to the control arm of 4.3 years (95% CI 3.8–4.8 years). Acute toxicity scores for urinary and bowel functions were comparable. Acute rectal discharge by score, was more significant in the treatment cohort compared with the control group (P=0.025). The authors concluded, "this suggest the therapeutic ratio is in favor of using HDR brachytherapy as a boost with external beam radiotherapy in intermediate and high risk localized carcinoma of the prostate."

A nonrandomized comparison of biochemical outcomes using an ultra-high dose of conventionally fractionated intensity-modulated radiation therapy (IMRT) versus a lower dose of IMRT combined with high-dose-rate (HDR) brachytherapy was performed retrospectively by Deutsch (2010). Six hundred thirty individuals were treated at a single institution with 160 participants receiving combination HDR iridium-192 brachytherapy boost followed by IMRT. Ultra-high-dose IMRT of 86.4 Gy was used to treat 470 individuals. Participants were stratified into risk groups based on NCCN's clinical and pathological parameters. In general, HDR boost was not offered to individuals with low-risk prostate cancers, except in cases with multiple positive cores or those with other high-risk factors. Those with intermediate- and high-risk classifications were given both options. Androgen deprivation therapy was utilized for those in the high-risk group and those in the intermediate-risk group with particularly poor pathologic features. A statistically significant improvement in PSA relapse-free survival (PRFS) for those treated with HDR boost with IMRT at 5-year was 97.7% compared to 82% for those treated with ultra-high-dose IMRT (p<0.0001). Response analysis based on risk groups for the intermediate-risk cohort remained significant, but PRFS was not statistically significant for those in the low- or high-risk cohort. Stratified 5-year actuarial PRFS for HDR boost with IMRT compared to ultrahigh-dose IMRT were 100% vs. 98% (p=0.71) for low-risk, 98% vs. 84% (P<0.001) for intermediate-risk and high-risk 93% vs. 71% (p=0.23), respectively. The authors commented the nonsignificant results for the high-risk group was "likely related to the confounding implications of androgen deprivation therapy, smaller patient numbers and events, a higher probability of micrometastatic disease at the time of treatment, and the modest followup." The authors further stated none of the failures in the high-risk HDR group was local, which suggested possible metastatic spread prior to radiation treatment. "Should the benefit seen in our high-risk cohort persist and become statistically significant, it would likely suggest a benefit of local control of disease on subsequent development of distant metastases" (Deutsch, 2010).

The ACR-ASTRO guideline (2010) notes HDR brachytherapy may be combined with EBRT for the treatment of prostate cancer in any risk group. Guidelines for treatment of prostate cancer from the American Urological Association (AUA, 2007) note high recurrence rates for individuals with high-risk localized prostate cancer. Treatment options for the management include active surveillance, interstitial prostate brachytherapy, external beam radiotherapy, and radical prostatectomy. Despite the lack of high-quality evidence of treatment benefit among this cohort, a high risk of disease progression and death from disease, the AUA notes active treatment may be a preferred option.

The National Comprehensive Cancer Network® (NCCN, 2014) Clinical Practice Guideline notes monotherapy with permanent low-dose rate (LDR) brachytherapy for men with low-risk of recurrence, clinically confined prostate cancers (T1c-T2a, Gleason 2-6, PSA less than 10 ng/ml) and expected survival of 10 or more years is a popular regimen. Combination LDR brachytherapy with EBRT and androgen deprivation therapy may be efficacious in some intermediate and high-risk individuals. Men with intermediate-risk or recurrent cancers as defined by NCCN include individuals with T2b to T2c tumors or Gleason score of 7, or a PSA value of 10 to 20 ng/mL. Men with high risk of recurrence after therapy include those with T3a clinically localized tumor, or Gleason score of 8 to 10 or PSA level greater than 20 ng/mL. High-dose rate (HDR) brachytherapy can be used alone or in combination with EBRT instead of LDR brachytherapy. Escalation of radiation doses may be achieved safely by combining EBRT with HDR brachytherapy in treatment of individuals with intermediate or high risk prostate cancer.

Soft Tissue Sarcoma
The use of brachytherapy as part of a multidisciplinary and combined treatment approach in the management of soft tissue sarcoma has become standard of care. Brachytherapy is commonly utilized in conjunction with surgical resection with positive or close margins to improve therapeutic results (NCCN, 2014). The NCCN panel "recommends brachytherapy as a radiation boost for positive or close margins." It was noted the use of brachytherapy as a boost afer preoperative radiation for individuals with widely negative margins are no longer used by many institutions because of 95% local control, rates with preoperative radiation at 50 Gy and negative margins. In addition, specialty consensus opinions support the use of brachytherapy to treat soft tissue sarcomas with close or positive margins. The American Brachytherapy Society identifies soft tissue sarcoma as an indication for brachytherapy applications.

Uterine, Cervical, Endometrial, and Vulvar/Vaginal Tumors
Brachytherapy is considered the standard of care in individuals with gynecologic malignancies, including uterine, cervical, endometrial, and vulvar/vaginal tumors. In a Cochrane Review (Wang, 2010) a meta-analysis of published trial data compared high-dose rate (HDR) and low-dose rate (LDR) brachytherapy treatment for uterine and cervical cancer. The authors determined there were no significant differences in the outcomes between LDR and HDR brachytherapy for overall survival, relapse-free survival, local control rate, recurrence and rates of metastases.

Consensus guidelines by the American Brachytherapy Society (Beriwal, 2012) recommend interstitial brachytherapy to treat vaginal cancer and recurrent cancers in the vagina.

Other energy source for brachytherapy: Electronic Brachytherapy
In December 2005, Xoft, Inc. (Fremont, CA) received U.S. Food and Drug Administration (FDA) 510K clearance for the Axxent™ Electronic Brachytherapy System. The FDA approved the Xoft Axxent electronic system as similar to predicate device that utilizes 192IR seeds as the source of radiation. The Axxent system is a proprietary form of providing electronic brachytherapy for accelerated partial breast irradiation for early stage breast cancer. Electronic brachytherapy is a non-radioactive, isotope-free treatment requiring minimal shielding, provided via a miniaturized X-ray tube. Therefore, this device is not subject to regulatory requirements by the U.S. Nuclear Regulatory Commission (NRC) or public health departments at this time. The system utilizes disposable micro-miniature X-ray radiation sources. This will allow radiation services to be provided in a variety of settings and not limited to heavily shielded settings. Axxent electronic brachytherapy is approved to deliver intracavitary or interstitial radiation to the surgical margins following lumpectomy for breast cancer. Axxent is not approved to provide whole breast irradiation. Although the device received FDA approval, due to the paucity of comparative clinical trials of high dose rate electronic brachytherapy and standard brachytherapy methods, the long term safety and efficacy of the high dose rate electronic brachytherapy procedure for the treatment of breast cancer or other carcinomas have not been determined.

An updated literature search revealed some industry-sponsored case reports and case series reporting on the feasibility of delivering the planned doses of electronic brachytherapy for treatment of breast cancer and endometrial cancer and short term adverse events (Dickler, 2010; Dooley, 2010; Mehta, 2010). However, the published literature did not compare the long-term effectiveness and safety data between the electronic brachytherapy devices versus outcomes from conventional brachytherapy utilizing radioactive sources. After review of the published data, specialty consensus opinion does not recommend the use of electronic brachytherapy due to the lack of published literature investigating the comparative effectiveness and long-term clinical outcomes to standard sources of radiation.

Background/Overview

Breast Brachytherapy as a Boost to Whole Breast Irradiation
Breast conservation surgery (BCS) and radiotherapy (RT) of the conserved breast became widely accepted in the last decade as an alternative to mastectomy for the treatment of early invasive breast cancer. The external beam radiation treatment may be preceded, or followed by, a supplemental or "boost" dose administered to the primary tumor site. When brachytherapy is used as a boost, the radiation is delivered either as a low dose or high dose rate and the radioactive material is left in place until the dose is delivered. For low-dose-rate this usually is 2 to 3 days and for high dose it is a matter of minutes (but may be repeated 1 or 2 times a day for 1 or 2 days).

Breast Brachytherapy as an Alternative to Whole Breast Irradiation
In contrast to whole breast irradiation, brachytherapy can be completed in a much shortened treatment course.  Because of this shortened time frame, there has been interest in breast brachytherapy as a sole modality after lumpectomy. The recent application of brachytherapy is based partly on the observation that most ipsilateral breast recurrences after breast-conserving surgery and radiation therapy occur at or near the tumor bed, with only a minority of recurrences located elsewhere in the breast. In addition, in trials of breast-conserving surgery with versus without radiation therapy, most recurrences also occurred at or near the tumor bed suggesting that undetected multicentric disease may not be common. Together, these findings suggested that tumor bed irradiation may provide the major benefit from external beam radiation therapy. Also, external beam radiation therapy typically is delivered in fractionated doses over a course of 5 to 7 weeks. This extended treatment course may be difficult for some individuals for example, those living in remote locations, or the elderly or disabled. Brachytherapy usually is delivered over a week. This shortened treatment course, which has been termed accelerated partial-breast irradiation, may increase the proportion of individuals choosing breast-conserving surgery.

There are various brachytherapy techniques that differ in the timing of implantation relative to other components of breast-conserving therapy, the radiation dose rate, the loading technique, the number and volumetric distribution of radioactive sources, and the radioisotopes used. Older studies of local boost brachytherapy included temporarily implanted needles, wires, or seeds after participants recovered from surgery and completed whole-breast radiation therapy. More recently, investigators have perioperatively implanted hollow needles or catheters that guide placement of the radioactive material. This can be done during the initial lumpectomy if the decision to use brachytherapy has already been made or at the time of a re-excision if the lumpectomy specimen has positive surgical margins. Intraoperative implantation avoids the need for a separate surgical procedure with anesthesia for brachytherapy. Whether intra- or post-operative, these methods are collectively termed interstitial brachytherapy and use multiple radioactive sources placed to deliver a prescribed radiation dose to a defined target volume.

Phase II studies have suggested that in individuals with small, well defined tumors, partial breast irradiation using brachytherapy may provide the same levels of local tumor control compared to whole breast irradiation. The vast majority of individuals who receive partial breast irradiation are treated with either interstitial irradiation or more recently, balloon brachytherapy via a balloon catheter system called the Mammosite®RTS device. The device is implanted in the lumpectomy cavity during or shortly after breast-conserving surgery. The balloon is inflated with sterile solution of contrast media in saline, and its position is confirmed radiographically using computed tomography. A high-dose rate source of iridium-192 is then centrally positioned within the applicator by a remote afterloader. This system is used to deliver 34 Gy in 10 fractions over 5 days. Thus, balloon brachytherapy uses a single radioactive source that delivers radiation to a spherical or elliptical target volume. Like interstitial brachytherapy, it can be used to deliver local boost or accelerated partial-breast radiation therapy.

Both LDR and HDR interstitial techniques have been used, with HDR techniques increasing in popularity. In the LDR technique, temporarily implanted radioactive seeds deliver radiation therapy continuously over a course of 4 days and then are removed. This treatment is generally an inpatient procedure. In the HDR technique, a computer-controlled device pushes a highly radioactive isotope into a catheter that has been placed into the tumor bed. The individual is exposed to the radiation therapy for a brief period (i.e., up to 15 minutes) and then the radioactive source is withdrawn. High-dose rate brachytherapy is typically administered on an outpatient basis in 8 fractions given twice daily over 4 days.

Cholangiocarcinoma
Cholangiocarcinoma is rare type of cancer that develops in cells that line the bile ducts and the diagnosis includes the anatomic site, either intrahepatic or extrahepatic. Surgical resection is the only potentially curative therapy for cholangiocarcinomas, with liver transplantation the only "other potentially curative option for patients with extrahepatic cholangiocarcinoma" (NCCN, 2014). Brachytherapy is used to treat the cholangiocarcinoma as well as maintain the patency of the stent due to tumor obstruction.

Lung Brachytherapy
Endobronchial brachytherapy describes the delivery of radiation therapy directly to endobronchial lesions, using either permanent interstitial implantation of radioactive seeds or a temporary afterloading implant. The technique permits targeted radiation while minimizing exposure to surrounding radiosensitive structures, such as normal lung, heart, and spinal cord.

Endobronchial brachytherapy has been most thoroughly investigated as a treatment of non-small cell lung cancer, specifically for early-stage nonresectable tumors without extraluminal extension, or as a palliative treatment of obstructing primary or metastatic tumors. The technique can be performed in the inpatient setting (30 to 72 hours) using low-dose rate radiotherapy, or more commonly as an outpatient procedure using multiple sessions of high-dose rate radiotherapy. Iridium-192 has become the radioisotope of choice for high-dose therapy. Two to 5 fractions delivered weekly is a typical schedule, although some individuals may receive hyperfractionated radiotherapy, i.e., twice daily treatments for 2 consecutive days. However, doses vary among institutions, and there is no clear consensus as to the optimal dose and frequency of fractionation for brachytherapy.

In the outpatient setting, the individual receives local anesthesia and monitored sedation. A flexible bronchoscope is passed transnasally; a separate port on the bronchoscope allows passage of the afterloading catheter to the target lesion. Once the catheter is placed, the radioisotope can be administered by the high-dose radiotherapy afterloading machine. Individuals with potential airway compromise due to bleeding may require treatment with a rigid bronchoscope, which requires general anesthesia and frequently an overnight hospitalization.

Endobronchial brachytherapy represents one approach to the local treatment of endobronchial lesions. Other technologies include electrocoagulation, cryosurgery, laser resection, and endobronchial stent placement. In some instances, the therapies may be used together, such as using laser therapy for initial debulking followed by brachytherapy. In addition, brachytherapy has been investigated as a "boost" to curative external beam radiation therapy.

Esophageal cancer
Options to treat esophageal cancer include chemotherapy, surgery, radiation therapy and photodynamic therapy. Brachytherapy for esophageal cancer involves implantation of radioactive seeds or devices and is often times used in combination with other treatment modalities. Brachytherapy is typically utilized to palliate symptoms of the cancer, which may include pain, and difficulty swallowing.

Head and Neck Carcinoma
Radiation therapy is a common treatment modality for head and neck carcinomas, and may be combined with other methods such as chemotherapy, external beam radiotherapy or surgery. Brachytherapy may involve temporary or permanent placement of radioactive sources at the site of the tumor(s).

Ocular cancers:
Choroidal Melanoma
According to the American Cancer Society (ACS), cancers originating in the eyeball, also known as intraocular cancer, are rare. Melanoma is the most common primary cancer originating in the eyeball (ACS, 2014). Uveal melanomas are the most common subset of intraocular cancer, with 90% of the cases occurring in the choroid. The choroid cells in the uvea are comprised of pigment similar to the melanocytes in skin. Surgical options include resection of small tumors or enucleation or removal of the entire eyeball. Brachytherapy, external radiation therapy, laser surgery and chemotherapy are therapeutic options. Treatment decisions are determined by the location and size of the tumors.

Prostate Brachytherapy
Brachytherapy is a common treatment option for clinically localized prostate cancer. The most common application involves the permanent implantation of low-dose-rate radioactive isotopes, in the form of seeds, into the prostate gland. This is done under general anesthesia as an outpatient surgery procedure. The seeds are inserted into the prostate using preloaded needles and ultrasonic guidance to assist with correct placement. The number of seeds depends on the size of the prostate, but typically between 60 to 120 seeds are required. A computerized tomography scan is usually performed at some time after the procedure to determine the quality of seed placement. More may be added if placement is inadequate. The choice of radioactive source, iodine or palladium is usually based on physician preference. Iodine has a half-life of 60 days while palladium has a shorter half-life of 17 days with a slightly higher dose rate. Locally advanced cancers may be undertreated by permanent brachytherapy alone and these individuals are usually treated by brachytherapy in combination with external beam radiation therapy.

Another form of brachytherapy that has been used to treat prostate cancer is high-dose-rate (HDR) brachytherapy. This technique uses a high activity radioisotope, such as iridium-192, which delivers radiation at a high dose rate through needle catheters inserted into the prostate. The isotope is left in place for a predetermined time, known as the 'dwell' time, which typically falls in the range of 8 to 10 minutes. The dwell time can be altered to control dose distribution to the tumor and surrounding tissue. This type of treatment is commonly referred to as 'temporary brachytherapy' since the radioactive source is removed from the individual at the end of each HDR treatment session. The radiation may be delivered in one or two sessions each day over the course of one to two days. Theoretically, HDR brachytherapy achieves greater dose accuracy and control as it permits more precise delivery of radiation compared to permanent seed implantation in which the dose cannot be altered after seed implantation. In addition, when using permanent seed implantation, swelling (edema) of the prostate and other factors may cause the permanent seed to "migrate" and thus become less effective in delivering the dose to the precise target. HDR brachytherapy is proposed as an adjunct to EBRT to provide local boost radiation in individuals with locally advanced prostate cancer. There exists some risk of urethral strictures with HDR treatment (4% – 8%) and a slightly increased incidence of rectal fistula. Otherwise the treatment is generally well tolerated. Overall, late toxicity is comparable to local dose-escalated external radiation treatment.

Soft Tissue Sarcoma Brachytherapy
Soft tissue sarcomas are a heterogenous group of tumors that may originate in the mesodermal tissues of the extremities, trunk, retroperitoneum or head and neck in adults and from mesenchymal tissues in children. Tumors arising from the gastrointestinal stroma are called gastrointestinal stromal tumors (GIST) with occur most frequently in the stomach and the small intestine (National Cancer Institute, 2008). Preoperative, intraoperative or postoperative radiation therapies are commonly used as part of a combined modality approach in managing the disease.                                                        

Uterine, Cervical, Endometrial, and Vulvar/Vaginal Tumors
Brachytherapy can be used to prevent local cancer recurrences after surgery (adjuvant therapy) or for the treatment of recurrent uterine, cervical and endometrial and vulvar/vaginal cancer. Radiation is directly placed in the area of the cancer or in the area where unseen cancer is suspected. For uterine cancer, this is the "vaginal cuff" region where the incision was made when the uterus was removed. Brachytherapy does not penetrate very deep and external beam radiation therapy is often combined with brachytherapy for treatment of uterine cancer. In the case of endometrial cancer, the radioactive pellets are placed in the vagina, after hysterectomy, to prevent cancer recurrence in the vaginal cuff.

Radioactive material is placed directly into the cervix for cervical cancer. Placing the radiation in this manner allows a high radiation dose to be delivered directly to the cancer, while reducing radiation to surrounding normal organs, such as the rectum and bladder. During a procedure in the operating room, a small device is placed into the cervix and vagina. This device is later "loaded" with the radiation capsules while the individual is in a lead-shielded hospital room. The radioactive material is left in place for 1-3 days. This procedure may be performed once or twice during the course of treatment. The individual is discharged from the hospital once the device is removed from the cervix. Primary vaginal cancer is rare and occurs in approximately 1% of cancers of the female reproductive system (ACS, 2014). Intracavitary vaginal brachytherapy alone may be used for selected individuals with superficial disease. Tumors that are more extensive may require interstitial brachytherapy to achieve adequate tissue doses (Bradley, 2006).

Electronic Brachytherapy
Historically, brachytherapy utilized radioactive sources to produce the therapeutic radiation doses. Newer technology utilizes non-radioactive, isotope-free electronic brachytherapy. The use of electronic brachytherapy allows treatment to be provided in environments that are not heavily shielded. However, the long term efficacy and safety of utilizing electronic brachytherapy versus conventional radioactive sources to provide brachytherapy have not been published.

Definitions

Boost: An additional dose of radiation to a reduced size radiation field.

Brachytherapy (also known as internal radiation): A type of radiation treatment used to stop the growth of cancer cells by implanting radioactive material directly into the tumor or into the surrounding tissues.

Breast-conserving surgery: A treatment alternative to mastectomy for early stage breast cancer that consists of tumor removal (lumpectomy) followed by external radiation to the whole breast.

External beam radiation therapy (EBRT): A form of radiation therapy (i.e., three dimensional conformal radiation therapy [3D-CRT], intensity modulated radiation therapy [IMRT], and image guided radiation therapy [IGRT]) used to stop the growth of cancer cells. A linear accelerator directs a photon or electron beam from outside the body through normal or healthy body tissue to reach the cancer. The radiation is typically given 5 days a week for a period of three to eight weeks.

Extrahepatic bile duct cancers: A type of cancer that originates outside of the bile duct. Perihilar and distal tumors comprise the extrahepatic category.

Gleason Grading System: A prostate cancer grading system based on a number range from one to five; the lower the number, the lower the grade, and the slower the cancer growth.

Gleason score: Represents the sum of the two most common Gleason grades observed by the pathologist on a specimen, the first number is the most frequent grade seen.

Head and neck cancers: Cancers arising from the oral cavity and lips, larynx, hypopharynx, oropharynx, nasopharynx, paranasal sinuses and nasal cavity, salivary glands, mucosal melanoma and occult primaries in the head and neck region are considered "head and neck cancers." Cancer of the cervical esophagus, trachea, lymphoma, and thyroid cancer are not "head and neck cancers" even when they arise in that body area.

High dose rate (HDR) brachytherapy (temporary): Involves implantation of high intensity radiation for a short time period of 3 to 10 minutes and then removing the radiation source. The most commonly used source is Iridium.

Interstitial implant: A procedure in which radioactive material is placed directly into a tumor site.

Intrahepatic bile duct cancers: Cancers that develop in the smaller bile duct branches inside the liver. These can sometimes be confused with cancers called hepatocellular carcinomas that start in the liver cells.

Low dose rate (LDR) brachytherapy (temporary): A low dose of radiation is delivered over the course of several days, after which the radiation source is removed. This requires an inpatient hospital stay; the most commonly used sources are Cesium and Radium.

Low dose rate (LDR) brachytherapy (permanent): Permanently implanted radioactive material (most commonly iodine-125 and palladium-103 radioisotopes).

Partial breast irradiation: Radiation focused at the tumor bed of the breast, after prior breast conserving surgery. An alternative to whole breast irradiation, breast brachytherapy is one technique of delivering partial breast irradiation.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Breast cancer, specific procedures
When Services may be Medically Necessary when criteria are met:

CPT 
19296Placement of radiotherapy afterloading balloon catheter into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; on date separate from partial mastectomy
19297Placement of radiotherapy afterloading balloon catheter into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; concurrent with partial mastectomy
19298Placement of radiotherapy afterloading brachytherapy catheters (multiple tube and button type) into the breast for interstitial radioelement application following (at the time of or subsequent to) partial mastectomy, includes imaging guidance 
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
174.0-174.9Malignant neoplasm of female breast
175.0-175.9Malignant neoplasm of male breast
198.81Secondary malignant neoplasm of breast
233.0Carcinoma in situ of breast
  
ICD-10 Procedure[For dates of service on or after10/01/2015]
0HHT01Z-0HHVX1ZInsertion of radioactive element into breast [right, left or bilateral, by approach; includes codes 0HHT01Z, 0HHT31Z, 0HHT71Z, 0HHT81Z, 0HHTX1Z, 0HHU01Z, 0HHU31Z, 0HHU71Z, 0HHU81Z, 0HHUX1Z, 0HHV01Z, 0HHV31Z, 0HHV71Z, 0HHV81Z, 0HHVX1Z]
0HHW01Z-0HHXX1ZInsertion of radioactive element into nipple [right or left, by approach; includes codes 0HHW01Z, 0HHW31Z, 0HHW71Z, 0HHW81Z, 0HHWX1Z, 0HHX01Z, 0HHX31Z, 0HHX71Z, 0HHX81Z, 0HHXX1Z]
DM1097Z- DM119YZHigh dose rate brachytherapy of breast [includes codes DM1097Z, DM1098Z, DM1099Z, DM109BZ, DM109CZ, DM109YZ, DM1197Z, DM1198Z, DM1199Z, DM119BZ, DM119CZ, DM119YZ]
DM10B7Z- DM11BYZLow dose rate brachytherapy of breast [includes codes DM10B7Z,  DM10B8Z,  DM10B9Z,  DM10BBZ,  DM10BCZ,  DM10BYZ, DM11B7Z, DM11B8Z, DM11B9Z, DM11BBZ, DM11BCZ, DM11BYZ]
  
ICD-10 Diagnosis[For dates of service on or after10/01/2015]
C50.011-C50.929Malignant neoplasm of breast
C79.81Secondary malignant neoplasm of breast
D05.00-D05.92Carcinoma in situ of breast

When Services are Investigational and Not Medically Necessary for the treatment of breast cancer:
For the procedure codes listed above, when criteria are not met, for all other diagnoses, or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

Cholangiocarcinoma, specific procedure
When Services may be Medically Necessary when criteria are met: 

CPT 
47999Unlisted procedure, biliary tract [when specified as placement of radioelement for cholangiocarcinoma]
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
155.1Malignant neoplasm of intrahepatic bile ducts
156.1Malignant neoplasm of extrahepatic bile ducts
  
ICD-10 Procedure[For dates of service on or after10/01/2015]
0FHB01Z-0FHB81ZInsertion of radioactive element into hepatobiliary duct [by approach; includes codes 0FHB01Z, 0FHB31Z, 0FHB41Z, 0FHB71Z, 0FHB81Z]
DF1297Z- DF129YZHigh dose rate brachytherapy of bile ducts [includes codes DF1297Z,  DF1298Z,  DF1299Z,  DF129BZ, DF129CZ, DF129YZ]
DF12B7Z- DF12BYZLow dose rate brachytherapy of bile ducts [includes codes DF12B7Z, DF12B8Z, DF12B9Z, DF12BBZ, DF12BCZ, DF12BYZ]
  
ICD-10 Diagnosis[For dates of service on or after10/01/2015]
C22.1Intrahepatic bile duct carcinoma
C24.0Malignant neoplasm of extrahepatic bile duct

When Services are Investigational and Not Medically Necessary:
For placement of radioelement for cholangiocarcinoma when criteria are not met and for all other diagnoses

Ocular brachytherapy, specific procedures
When Services may be Medically Necessary when criteria are met:

CPT 
67218Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions; radiation by implantation of source (includes removal of source)
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
190.0Malignant neoplasm of eyeball, except conjunctiva, corneal, retina, and choroid
190.5Malignant neoplasm of retina
190.6Malignant neoplasm of choroid
234.0Carcinoma in situ of eye
  
ICD-10 Procedure[For dates of service on or after10/01/2015]
08H031Z-08H1X1ZInsertion of radioactive element into eye [right or left, by approach; includes codes 08H031Z, 08H0X1Z, 08H131Z, 08H1X1Z]
D81097Z- D8109YZHigh dose rate brachytherapy of the eye [includes codes D81097Z, D81098Z, D81099Z, D8109BZ, D8109CZ, D8109YZ]
D810B7Z- D810BYZLow dose rate brachytherapy of the eye [includes codes D810B7Z, D810B8Z, D810B9Z, D810BBZ, D810BCZ, D810BYZ]
  
ICD-10 Diagnosis[For dates of service on or after10/01/2015]
C69.20-C69.22Malignant neoplasm of retina
C69.30-C69.32Malignant neoplasm of choroid
C69.40-C69.42Malignant neoplasm of ciliary body
D09.20-D09.22Carcinoma in situ of eye

When Services are Investigational and Not Medically Necessary for ocular brachytherapy:
For the procedure and diagnoses codes listed above when criteria are not met, or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

Endobronchial tumors, specific procedure
When Services may be Medically Necessary when criteria are met:

CPT 
31643 Bronchoscopy; with placement of catheter(s) for intracavitary radioelement application 
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
162.2-162.9 Malignant neoplasm of bronchus and lung 
197.0 Secondary malignant neoplasm of lung (bronchus) 
209.21Malignant carcinoid tumor of the bronchus and lung
231.2 Carcinoma in situ of bronchus and lung 
231.9Carcinoma in situ of respiratory system; part unspecified
  
ICD-10 Procedure[For dates of service on or after10/01/2015]
0BH001Z-0BH081ZInsertion of radioactive element into tracheobronchial tree [by approach; includes codes 0BH001Z, 0BH031Z, 0BH041Z, 0BH071Z, 0BH081Z]
0BHK01Z-0BHL81ZInsertion of radioactive element into lung [right or left, by approach; includes codes 0BHK01Z, 0BHK31Z, 0BHK41Z, 0BHK71Z, 0BHK81Z, 0BHL01Z, 0BHL31Z, 0BHL41Z, 0BHL71Z, 0BHL81Z]
DB1197Z- DB129YZHigh dose rate brachytherapy of bronchus & lung [includes codes DB1197Z, DB1198Z, DB1199Z, DB119BZ, DB119CZ, DB119YZ, DB1297Z, DB1298Z, DB1299Z, DB129BZ, DB129CZ, DB129YZ]
DB11B7Z- DB12BYZLow dose rate brachytherapy of bronchus & lung [includes codes DB11B7Z, DB11B8Z, DB11B9Z, DB11BBZ, DB11BCZ, DB11BYZ, DB12B7Z, DB12B8Z, DB12B9Z, DB12BBZ, DB12BCZ, DB12BYZ]
  
ICD-10 Diagnosis[For dates of service on or after10/01/2015]
C34.00-C34.92Malignant neoplasm of bronchus and lung
C7A.090Malignant carcinoid tumor of the bronchus and lung
C78.00-C78.02Secondary malignant neoplasm of lung
D02.20-D02.22Carcinoma in situ of bronchus and lung 

When Services are Investigational and Not Medically Necessary:
For the procedure code listed above when criteria are not met, for all other diagnoses, or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

Esophageal cancer, specific procedure
When Services are Medically Necessary: 

CPT 
43499Unlisted procedure, esophagus [when specified as placement of radioelement for esophageal tumor]
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
150.0-150.9Malignant neoplasm of esophagus
230.1Carcinoma in situ of esophagus
  
ICD-10 Procedure[For dates of service on or after10/01/2015]
0DH501Z-0DH581ZInsertion of radioactive element into esophagus [by approach; includes codes 0DH501Z, 0DH531Z, 0DH541Z, 0DH571Z, 0DH581Z]
DD1097Z- DD109YZHigh dose rate brachytherapy of the esophagus [includes codes DD1097Z, DD1098Z, DD1099Z, DD109BZ, DD109CZ, DD109YZ]
DD10B7Z- DD10BYZLow dose rate brachytherapy of the esophagus [includes codes DD10B7Z, DD10B8Z, DD10B9Z, DD10BBZ, DD10BCZ, DD10BYZ]
  
ICD-10 Diagnosis[For dates of service on or after10/01/2015]
C15.3-C15.9Malignant neoplasm of esophagus
D00.1Carcinoma in situ of esophagus

When Services are Investigational and Not Medically Necessary:
For esophageal placement of radioelement, for all other diagnoses

Head and neck cancer, specific procedure
When Services are Medically Necessary:

CPT 
41019Placement of needles, catheters, or other device(s) into the head and/or neck region (percutaneous, transoral, or transnasal) for subsequent interstitial radioelement application
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
140.0-149.9Malignant neoplasm of lip, oral cavity, and pharynx
160.0-161.9Malignant neoplasm of nasal cavities, middle ear, and accessory sinuses, larynx
195.0Malignant neoplasm of head, face, and neck
230.0Carcinoma in situ of lip, oral cavity, and pharynx
231.0Carcinoma in situ of larynx
  
ICD-10 Procedure[For dates of service on or after10/01/2015]
0CH701Z-0CH7X1ZInsertion of radioactive element into tongue [by approach; includes codes 0CH701Z, 0CH731Z, 0CH7X1Z]
0WH001Z-0WH041ZInsertion of radioactive element into head [by approach; includes codes 0WH001Z, 0WH031Z, 0WH041Z]
0WH201Z-0WH241ZInsertion of radioactive element into face [by approach; includes codes 0WH201Z, 0WH231Z, 0WH241Z]
0WH301Z-0WH341ZInsertion of radioactive element into oral cavity and throat [by approach; includes codes 0WH301Z, 0WH331Z, 0WH341Z]
0WH601Z-0WH641ZInsertion of radioactive element into neck [by approach; includes codes 0WH601Z, 0WH631Z, 0WH641Z]
D71397Z-D7139YZHigh dose rate (HDR) brachytherapy of neck lymphatics [includes codes D71397Z, D71398Z, D71399Z, D7139BZ, D7139CZ, D7139YZ]
D91397Z-D9139YZHigh dose rate (HDR) brachytherapy of hypopharynx [includes codes D91397Z, D91398Z, D91399Z, D9139BZ, D9139CZ, D9139YZ]
D91497Z-D9149YZHigh dose rate (HDR) brachytherapy of mouth [includes codes D91497Z, D91498Z, D91499Z, D9149BZ, D9149CZ, D9149YZ]
D91597Z-D9159YZHigh dose rate (HDR) brachytherapy of tongue [includes codes D91597Z, D91598Z, D91599Z, D9159BZ, D9159CZ, D9159YZ]
D91797Z-D9179YZHigh dose rate (HDR) brachytherapy of sinuses [includes codes D91797Z, D91798Z, D91799Z, D9179BZ, D9179CZ, D9179YZ]
D91897Z-D9189YZHigh dose rate (HDR) brachytherapy of hard palate [includes codes D91897Z, D91898Z, D91899Z, D9189BZ, D9189CZ, D9189YZ]
D91997Z-D9199YZHigh dose rate (HDR) brachytherapy of soft palate [includes codes D91997Z, D91998Z, D91999Z, D9199BZ, D9199CZ, D9199YZ]
D91D97Z-D91D9YZHigh dose rate (HDR) brachytherapy of nasopharynx [includes codes D91D97Z, D91D98Z, D91D99Z, D91D9BZ, D91D9CZ, D91D9YZ]
D91F97Z-D91F9YZHigh dose rate (HDR) brachytherapy of oropharynx [includes codes D91F97Z, D91F98Z, D91F99Z, D91F9BZ, D91F9CZ, D91F9YZ]
DW1197Z-DW119YZHigh dose rate (HDR) brachytherapy of head & neck [includes codes DW1197Z, DW1198Z, DW1199Z, DW119BZ, DW119CZ, DW119YZ]
D713B7Z-D713BYZLow dose rate (LDR) brachytherapy of neck lymphatics [includes codes D713B7Z, D713B8Z, D713B9Z, D713BBZ, D713BCZ, D713BYZ]
D913B7Z-D913BYZLow dose rate (LDR) brachytherapy of hypopharynx [includes codes D913B7Z, D913B8Z, D913B9Z, D913BBZ, D913BCZ, D913BYZ]
D914B7Z-D914BYZLow dose rate (LDR) brachytherapy of mouth [includes codes D914B7Z, D914B8Z, D914B9Z, D914BBZ, D914BCZ, D914BYZ]
D915B7Z-D915BYZLow dose rate (LDR) brachytherapy of tongue [includes codes D915B7Z, D915B8Z, D915B9Z, D915BBZ, D915BCZ, D915BYZ]
D917B7Z-D917BYZLow dose rate (LDR) brachytherapy of sinuses [includes codes D917B7Z, D917B8Z, D917B9Z, D917BBZ, D917BCZ, D917BYZ]
D918B7Z-D918BYZLow dose rate (LDR) brachytherapy of hard palate [includes codes D918B7Z, D918B8Z, D918B9Z, D918BBZ, D918BCZ, D918BYZ]
D919B7Z-D919BYZLow dose rate (LDR) brachytherapy of soft palate [includes codes D919B7Z, D919B8Z, D919B9Z, D919BBZ, D919BCZ, D919BYZ]
D91DB7Z-D91DBYZLow dose rate (LDR) brachytherapy of nasopharynx [includes codes D91DB7Z, D91DB8Z, D91DB9Z, D91DBBZ, D91DBCZ, D91DBYZ]
D91FB7Z-D91FBYZLow dose rate (LDR) brachytherapy of oropharynx [includes codes D91FB7Z, D91FB8Z, D91FB9Z, D91FBBZ, D91FBCZ, D91FBYZ]
DW11B7Z-DW11BYZLow dose rate (LDR) brachytherapy of head & neck [includes codes DW11B7Z, DW11B8Z, DW11B9Z, DW11BBZ, DW11BCZ, DW11BYZ]
  
ICD-10 Diagnosis[For dates of service on or after10/01/2015]
C00.0-C14.8Malignant neoplasm of lip, oral cavity and pharynx
C30.0-C32.9Malignant neoplasm of nasal cavity, middle ear, accessory sinuses, larynx
C76.0Malignant neoplasm of head, face and neck
D00.00-D00.08Carcinoma in situ of lip, oral cavity and pharynx
D02.0Carcinoma in situ of larynx

When Services are Investigational and Not Medically Necessary:
For the procedure code listed above, for all other diagnoses

Penile cancer, specific procedure
When Services are Medically Necessary:

CPT 
55899Unlisted procedure, male genital system [when specified as placement of radioelement for penile tumor]
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
187.1Malignant neoplasm of prepuce
187.2Malignant neoplasm of glans penis
  
ICD-10 Procedure[For dates of service on or after10/01/2015]
 For the following codes when specified as penile brachytherapy:
0WHM01Z-0WHM41ZInsertion of radioactive element into male perineum [by approach; includes codes 0WHM01Z, 0WHM31Z, 0WHM41Z]
DW1697Z-DW169YZHigh dose rate brachytherapy of pelvic region [includes codes DW1697Z, DW1698Z, DW1699Z, DW169BZ, DW169CZ, DW169YZ]
DW16B7Z-DW16BYZLow dose rate brachytherapy of pelvic region [includes codes DW16B7Z, DW16B8Z, DW16B9Z, DW16BBZ, DW16BCZ, DW16BYZ]
  
ICD-10 Diagnosis[For dates of service on or after10/01/2015]
C60.0Malignant neoplasm of prepuce
C60.1Malignant neoplasm of glans penis
C60.8Malignant neoplasm of overlapping sites of penis

When Services are Investigational and Not Medically Necessary:
For penile placement of radioelement, for all other diagnoses

Prostate cancer, specific procedures
When Services may be Medically Necessary when criteria are met:

CPT 
55860Exposure of prostate, any approach, for insertion of radioactive substance
55862Exposure of prostate, any approach, for insertion of radioactive substance; with lymph node biopsy(s) (limited pelvic lymphadenectomy)
55865Exposure of prostate, any approach, for insertion of radioactive substance; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric and obturator nodes
55875Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy
76873Echography, transrectal; prostate volume study for brachytherapy treatment planning
  
HCPCS 
G0458Low dose rate (LDR) prostate brachytherapy services, composite rate
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
185Malignant neoplasm of prostate
233.4Carcinoma in situ of prostate
  
ICD-10 Procedure[For dates of service on or after10/01/2015]
0VH001Z-0VH081ZInsertion of radioactive element into prostate [by approach; includes codes 0VH001Z, 0VH031Z, 0VH041Z, 0VH071Z, 0VH081Z]
DV1097Z-DV109YZHigh dose rate brachytherapy of the prostate [includes codes DV1097Z, DV1098Z, DV1099Z, DV109BZ, DV109CZ, DV109YZ]
DV10B7Z-DV10BYZLow dose rate brachytherapy of the prostate [includes codes DV10B7Z, DV10B8Z, DV10B9Z, DV10BBZ, DV10BCZ, DV10BYZ]
  
ICD-10 Diagnosis[For dates of service on or after10/01/2015]
C61Malignant neoplasm of prostate
D07.5Carcinoma in situ of prostate

When Services are Investigational and Not Medically Necessary:
For the procedure codes listed above when criteria are not met, for all other diagnoses, or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

Soft tissue sarcoma, specific procedures
When Services may be Medically Necessary when criteria are met:

CPT 
20555Placement of needles or catheters into muscle and/or soft tissue for subsequent interstitial radioelement application (at the time of or subsequent to the procedure)
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
171.0-171.9Malignant neoplasm of connective and other soft tissue
198.89Secondary malignant neoplasm of other specified sites, other (specified as soft tissue)
  
ICD-10 Procedure[For dates of service on or after10/01/2015]
 For the following procedures when specified for soft tissue brachytherapy:
0JHS01Z-0JHS31ZInsertion of radioactive element into head and neck subcutaneous tissue and fascia [by approach; includes codes 0JHS01Z, 0JHS31Z]
0JHT01Z-0JHT31ZInsertion of radioactive element into trunk subcutaneous tissue and fascia [by approach; includes codes 0JHT01Z, 0JHT31Z]
0JHV01Z-0JHV31ZInsertion of radioactive element into upper extremity subcutaneous tissue and fascia [by approach; includes codes 0JHV01Z, 0JHV31Z]
0JHW01Z-0JHW31ZInsertion of radioactive element into lower extremity subcutaneous tissue and fascia [by approach; includes codes 0JHW01Z, 0JHW31Z]
0YH001Z-0YH141ZInsertion of radioactive element into buttock [right or left, by approach; includes codes 0YH001Z, 0YH031Z, 0YH041Z, 0YH101Z, 0YH131Z, 0YH141Z]
DW1197Z-DW119YZHigh dose rate (HDR) brachytherapy of head and neck [includes codes DW1197Z, DW1198Z, DW1199Z, DW119BZ, DW119CZ, DW119YZ]
DW1297Z-DW129YZHigh dose rate (HDR) brachytherapy of chest [includes codes DW1297Z, DW1298Z, DW1299Z, DW129BZ, DW129CZ, DW129YZ]
DW1397Z-DW139YZHigh dose rate (HDR) brachytherapy of abdomen [includes codes DW1397Z, DW1398Z, DW1399Z, DW139BZ, DW139CZ, DW139YZ]
DW11B7Z-DW11BYZLow dose rate (LDR) brachytherapy of head and neck [includes codes DW11B7Z, DW11B8Z, DW11B9Z, DW11BBZ, DW11BCZ, DW11BYZ]
DW12B7Z-DW12BYZLow dose rate (LDR) brachytherapy of chest [includes codes DW12B7Z, DW12B8Z, DW12B9Z, DW12BBZ, DW12BCZ, DW12BYZ]
DW13B7Z-DW13BYZLow dose rate (LDR) brachytherapy of abdomen [includes codes DW13B7Z, DW13B8Z, DW13B9Z, DW13BBZ, DW13BCZ, DW13BYZ]
  
ICD-10 Diagnosis[For dates of service on or after10/01/2015]
C49.0-C49.9Malignant neoplasm of other connective and other soft tissue
C79.89Secondary malignant neoplasm of other specified sites, other [specified as soft tissue]

When Services are Investigational and Not Medically Necessary:
For the procedure and diagnoses codes listed above when criteria are not met, for all other diagnoses, or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

Gynecologic cancers (Uterine, cervical, endometrial, and vulvar/vaginal tumors), specific procedures
When Services are Medically Necessary:

CPT 
55920Placement of needles or catheters into pelvic organs and/or genitalia (except prostate) for subsequent interstitial radioelement application
57155 Insertion of uterine tandem and/or vaginal ovoids for clinical brachytherapy
57156Insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy
58346Insertion of Heyman capsules for clinical brachytherapy
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
179Malignant neoplasm of uterus, part unspecified
180.0-180.9 Malignant neoplasm of cervix uteri
182.0-182.8 Malignant neoplasm of body of uterus
184.0-184.4Malignant neoplasm of vagina and vulva
198.82Secondary malignant neoplasm of genital organs [when specified as uterine, cervical, endometrial or vulvar/vaginal]
233.1 Carcinoma in situ of cervix uteri
233.2Carcinoma in situ of other and unspecified parts of uterus
233.31-233.32Carcinoma in situ of vagina, vulva
  
ICD-10 Procedure[For dates of service on or after10/01/2015]
0UHG01Z-0UHG81ZInsertion of radioactive element into vagina [by approach; includes codes 0UHG01Z, 0UHG31Z, 0UHG41Z, 0UHGX1Z, 0UHG71Z, 0UHG81Z]
0WHN01Z-0WHN41ZInsertion of radioactive element into female perineum [by approach; includes codes 0WHN01Z, 0WHN31Z, 0WHN41Z]
DU1197Z-DU119YZHigh dose rate (HDR) brachytherapy of cervix [includes codes DU1197Z; DU1198Z; DU1199Z; DU119BZ; DU119CZ; DU119YZ]
DU1297Z-DU129YZHigh dose rate (HDR) brachytherapy of uterus [includes codes DU1297Z; DU1298Z; DU1299Z; DU129BZ; DU129CZ; DU129YZ]
DU11B7Z-DU11BYZLow dose rate (LDR) brachytherapy of cervix [includes codes DU11B7Z; DU11B8Z; DU11B9Z; DU11BBZ; DU11BCZ; DU11BYZ]
DU12B7Z-DU12BYZLow dose rate (LDR) brachytherapy of uterus [includes codes DU12B7Z; DU12B8Z; DU12B9Z; DU12BBZ; DU12BCZ; DU12BYZ]
  
ICD-10 Diagnosis[For dates of service on or after10/01/2015]
C51.0-C51.9Malignant neoplasm of vulva
C52Malignant neoplasm of vagina
C53.0-C53.9Malignant neoplasm of cervix uteri
C54.0-C54.9Malignant neoplasm of corpus uteri
C55Malignant neoplasm of uterus, part unspecified
C79.82Secondary malignant neoplasm of genital organs [when specified as uterine, cervical, endometrial or vulvar/vaginal]
D06.0-D06.9Carcinoma in situ of cervix uteri
D07.0Carcinoma in situ of endometrium
D07.1Carcinoma in situ of vulva
D07.2Carcinoma in situ of vagina
D07.39Carcinoma in situ of other female genital organs [uterus]
Z85.41Personal history of malignant neoplasm of cervix uteri
Z85.42Personal history of malignant neoplasm of other parts of uterus

When Services are Investigational and Not Medically Necessary:
For the procedure codes listed above, for all other diagnoses, or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

Radiation Oncology brachytherapy procedures, not specific
When services are Medically Necessary: 

CPT 
76965Ultrasonic guidance for interstitial radioelement application
77326-77328Brachytherapy isodose calculation [includes codes 77326, 77327, 77328]
77761-77763Intracavitary radiation source application [includes codes 77761, 77762, 77763]
77776-77778Interstitial radiation source application [includes codes 77776, 77777, 77778]
77785-77787Remote afterloading high-intensity brachytherapy [includes codes 77785, 77786, 77787]
  
HCPCS 
Q3001Radioelements for brachytherapy, any type; each
  
ICD-9 Procedure[For dates of service prior to 10/01/2015]
92.27 Implantation or insertion of radioactive element
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
140.0-149.9Malignant neoplasm of lip, oral cavity, and pharynx
150.0-150.9Malignant neoplasm of esophagus
160.0-161.9Malignant neoplasm of nasal cavities, middle ear, and accessory sinuses, larynx
179Malignant neoplasm of uterus, part unspecified
180.0-180.9 Malignant neoplasm of cervix uteri
182.0-182.8 Malignant neoplasm of body of uterus
184.0-184.4Malignant neoplasm of vagina, vulva
195.0Malignant neoplasm of head, face, and neck
198.82Secondary malignant neoplasm of genital organs [when specified as uterine, cervical, endometrial or vulvar/vaginal]
230.0Carcinoma in situ of lip, oral cavity, and pharynx
230.1Carcinoma in situ of esophagus
231.0Carcinoma in situ of larynx
233.1 Carcinoma in situ of cervix uteri
233.2Carcinoma in situ of other and unspecified parts of uterus
233.31-233.32Carcinoma in situ of vagina, vulva
  
ICD-10 Diagnosis[For dates of service on or after10/01/2015]
C00.0-C14.8Malignant neoplasm of lip, oral cavity and pharynx
C15.3-C15.9Malignant neoplasm of esophagus
C30.0-C32.9Malignant neoplasm of nasal cavity, middle ear, accessory sinuses, larynx
C51.0-C51.9Malignant neoplasm of vulva
C52Malignant neoplasm of vagina
C53.0-C53.9Malignant neoplasm of cervix uteri
C54.0-C54.9Malignant neoplasm of corpus uteri
C55Malignant neoplasm of uterus, part unspecified
C76.0Malignant neoplasm of head, face and neck
C79.82Secondary malignant neoplasm of genital organs [when specified as uterine, cervical, endometrial or vulvar/vaginal]
D00.00-D00.08Carcinoma in situ of lip, oral cavity and pharynx
D00.1Carcinoma in situ of esophagus
D02.0Carcinoma in situ of larynx
D06.0-D06.9Carcinoma in situ of cervix uteri
D07.0Carcinoma in situ of endometrium
D07.1Carcinoma in situ of vulva
D07.2Carcinoma in situ of vagina
D07.39Carcinoma in situ of other female genital organs [uterus]
Z85.41Personal history of malignant neoplasm of cervix uteri
Z85.42Personal history of malignant neoplasm of other parts of uterus

When services may be Medically Necessary when criteria are met:
For the procedure codes listed above, for the following diagnosis codes

ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
155.1Malignant neoplasm of intrahepatic bile ducts
156.1Malignant neoplasm of extrahepatic bile ducts
162.2-162.9 Malignant neoplasm of bronchus and lung 
171.0-171.9Malignant neoplasm of connective and other soft tissue
174.0-174.9Malignant neoplasm of female breast
175.0-175.9Malignant neoplasm of male breast
185Malignant neoplasm of prostate
187.1Malignant neoplasm of prepuce
187.2Malignant neoplasm of glans penis
190.0Malignant neoplasm of eyeball, except conjunctiva, cornea, retina, and choroid
190.5Malignant neoplasm of retina
190.6Malignant neoplasm of choroid
197.0 Secondary malignant neoplasm of lung (bronchus) 
198.81Secondary malignant neoplasm of breast
198.89Secondary malignant neoplasm of other specified sites, other (specified as soft tissue)
209.21Malignant carcinoid tumor of the bronchus and lung
231.2 Carcinoma in situ of bronchus and lung 
231.9Carcinoma in situ of respiratory system, part unspecified
233.0Carcinoma in situ of breast
233.4Carcinoma in situ of prostate
234.0Carcinoma in situ of eye
  
ICD-10 Diagnosis[For dates of service on or after10/01/2015]
C22.1Intrahepatic bile duct carcinoma
C24.0Malignant neoplasm of extrahepatic bile duct
C34.00-C34.92Malignant neoplasm of bronchus and lung
C49.0-C49.9Malignant neoplasm of other connective and other soft tissue
C50.011-C50.929Malignant neoplasm of breast
C60.0Malignant neoplasm of prepuce
C60.1Malignant neoplasm of glans penis
C60.8Malignant neoplasm of overlapping sites of penis
C61Malignant neoplasm of prostate
C69.20-C69.22Malignant neoplasm of retina
C69.30-C69.32Malignant neoplasm of choroid
C69.40-C69.42Malignant neoplasm of ciliary body
C7a.090Malignant carcinoid tumor of the bronchus and lung
C78.00-C78.02Secondary malignant neoplasm of lung
C79.81Secondary malignant neoplasm of breast
C79.89Secondary malignant neoplasm of other specified sites, other [specified as soft tissue]
D02.20-D02.22Carcinoma in situ of bronchus and lung 
D05.00-D05.92Carcinoma in situ of breast
D07.5Carcinoma in situ of prostate
D09.20-D09.22Carcinoma in situ of eye

When services are Investigational and Not Medically Necessary:
For the procedure codes listed above when criteria are not met, for all other tumor diagnoses not listed, or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

When services are also Investigational and Not Medically Necessary:

CPT 
0182THigh dose rate electronic brachytherapy, per fraction
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
 All diagnoses
  
ICD-10 Procedure[For dates of service on or after10/01/2015]
0DHP01Z-0DHP81ZInsertion of radioactive element into rectum [by approach; includes codes 0DHP01Z, 0DHP31Z, 0DHP41Z, 0DHP71Z, 0DHP81Z]
0FHD01Z-0FHD81ZInsertion of radioactive element into pancreatic duct [by approach; includes codes 0FHD01Z, 0FHD31Z, 0FHD41Z, 0FHD71Z, 0FHD81Z]
0WH101Z-0WH141ZInsertion of radioactive element into cranial cavity [by approach; includes codes 0WH101Z, 0WH131Z, 0WH141Z]
0WH401Z-0WH541ZInsertion of radioactive element into jaw [upper and lower, by approach; includes codes 0WH401Z, 0WH431Z, 0WH441Z, 0WH501Z, 0WH531Z, 0WH541Z]
0WH801Z-0WH841ZInsertion of radioactive element into chest wall [by approach; includes codes 0WH801Z, 0WH831Z, 0WH841Z]
0WH901Z-0WHB41ZInsertion of radioactive element into pleural cavity [right or left, by approach; includes codes 0WH901Z, 0WH931Z, 0WH941Z, 0WHB01Z, 0WHB31Z, 0WHB41Z]
0WHC01Z-0WHC41ZInsertion of radioactive element into mediastinum [by approach; includes codes 0WHC01Z, 0WHC31Z, 0WHC41Z]
0WHD01Z-0WHD41ZInsertion of radioactive element into pericardial cavity [by approach; includes codes 0WHD01Z, 0WHD31Z, 0WHD41Z]
0WHF01Z-0WHF41ZInsertion of radioactive element into abdominal wall [by approach; includes codes 0WHF01Z, 0WHF31Z, 0WHF41Z]
0WHG01Z-0WHG41ZInsertion of radioactive element into peritoneal cavity [by approach; includes codes 0WHG01Z, 0WHG31Z, 0WHG41Z]
0WHH01Z-0WHH41ZInsertion of radioactive element into retroperitoneum [by approach; includes codes 0WHH01Z, 0WHH31Z, 0WHH41Z]
0WHJ01Z-0WHJ41ZInsertion of radioactive element into pelvic cavity [by approach; includes codes 0WHJ01Z, 0WHJ31Z, 0WHJ41Z]
0WHK01Z-0WHL41ZInsertion of radioactive element into back [upper or lower, by approach; includes codes 0WHK01Z, 0WHK31Z, 0WHK41Z, 0WHL01Z, 0WHL31Z, 0WHL41Z]
0WHP01Z-0WHP81ZInsertion of radioactive element into gastrointestinal tract [by approach; includes codes 0WHP01Z, 0WHP31Z, 0WHP41Z, 0WHP71Z, 0WHP81Z]
0WHQ01Z-0WHQ81ZInsertion of radioactive element into respiratory tract [by approach; includes codes 0WHQ01Z, 0WHQ31Z, 0WHQ41Z, 0WHQ71Z, 0WHQ81Z]
0WHR01Z-0WHR81ZInsertion of radioactive element into genitourinary tract [by approach; includes codes 0WHR01Z, 0WHR31Z, 0WHR41Z, 0WHR71Z, 0WHR81Z]
0XH201Z-0XH341ZInsertion of radioactive element into shoulder region [right or left, by approach; includes codes 0XH201Z, 0XH231Z, 0XH241Z, 0XH301Z, 0XH331Z, 0XH341Z]
0XH401Z-0XH541ZInsertion of radioactive element into axilla [right or left, by approach; includes codes 0XH401Z, 0XH431Z, 0XH441Z, 0XH501Z, 0XH531Z, 0XH541Z]
0XH601Z-0XH741ZInsertion of radioactive element into upper extremity [right or left, by approach; includes codes 0XH601Z, 0XH631Z, 0XH641Z, 0XH701Z, 0XH731Z, 0XH741Z]
0XH801Z-0XH941ZInsertion of radioactive element into upper arm [right or left, by approach; includes codes 0XH801Z, 0XH831Z, 0XH841Z, 0XH901Z, 0XH931Z, 0XH941Z]
0XHB01Z-0XHC41ZInsertion of radioactive element into elbow region [right or left, by approach; includes codes 0XHB01Z, 0XHB31Z, 0XHB41Z, 0XHC01Z, 0XHC31Z, 0XHC41Z]
0XHD01Z-0XHF41ZInsertion of radioactive element into lower arm [right or left, by approach; includes codes 0XHD01Z, 0XHD31Z, 0XHD41Z, 0XHF01Z, 0XHF31Z, 0XHF41Z]
0XHG01Z-0XHH41ZInsertion of radioactive element into wrist region [right or left, by approach; includes codes 0XHG01Z, 0XHG31Z, 0XHG41Z, 0XHH01Z, 0XHH31Z, 0XHH41Z]
0XHJ01Z-0XHK41ZInsertion of radioactive element into hand [right or left, by approach; includes codes 0XHJ01Z, 0XHJ31Z, 0XHJ41Z, 0XHK01Z, 0XHK31Z, 0XHK41Z]
0YH501Z-0YH641ZInsertion of radioactive element into inguinal region [right or left, by approach; includes codes 0YH501Z, 0YH531Z, 0YH541Z, 0YH601Z, 0YH631Z, 0YH641Z]
0YH701Z-0YH841ZInsertion of radioactive element into femoral region [right or left, by approach; includes codes 0YH701Z, 0YH731Z, 0YH741Z, 0YH801Z, 0YH831Z, 0YH841Z]
0YH901Z-0YHB41ZInsertion of radioactive element into lower extremity [right or left, by approach; includes codes 0YH901Z, 0YH931Z, 0YH941Z, 0YHB01Z, 0YHB31Z, 0YHB41Z]
0YHC01Z-0YHD41ZInsertion of radioactive element into  upper leg [right or left, by approach; includes codes 0YHC01Z, 0YHC31Z, 0YHC41Z, 0YHD01Z, 0YHD31Z, 0YHD41Z]
0YHF01Z-0YHG41ZInsertion of radioactive element into knee region [right or left, by approach; includes codes 0YHF01Z, 0YHF31Z, 0YHF41Z, 0YHG01Z, 0YHG31Z, 0YHG41Z]
0YHH01Z-0YHJ41ZInsertion of radioactive element into lower leg [right or left, by approach; includes codes 0YHH01Z, 0YHH31Z, 0YHH41Z, 0YHJ01Z, 0YHJ31Z, 0YHJ41Z]
0YHK01Z-0YHL41ZInsertion of radioactive element into ankle region [right or left, by approach; includes codes 0YHK01Z, 0YHK31Z, 0YHK41Z, 0YHL01Z, 0YHL31Z, 0YHL41Z]
0YHM01Z-0YHN41ZInsertion of radioactive element into foot [right or left, by approach; includes codes 0YHM01Z, 0YHM31Z, 0YHM41Z, 0YHN01Z, 0YHN31Z, 0YHN41Z]
 Radiation Oncology High Dose Rate (HDR) and Low Dose Rate (LDR):
D01097Z-D010BYZHDR and LDR brachytherapy of brain [includes codes D01097Z, D01098Z, D01099Z, D0109BZ, D0109CZ, D0109YZ, D010B7Z, D010B8Z, D010B9Z, D010BBZ, D010BCZ, D010BYZ]
D01197Z-D011BYZHDR and LDR brachytherapy of brain stem [includes codes D01197Z, D01198Z, D01199Z, D0119BZ, D0119CZ, D0119YZ, D011B7Z, D011B8Z, D011B9Z, D011BBZ, D011BCZ, D011BYZ]
D01697Z-D016BYZHDR and LDR brachytherapy of spinal cord [includes codes D01697Z, D01698Z, D01699Z, D0169BZ, D0169CZ, D0169YZ, D016B7Z D016B8Z, D016B9Z, D016BBZ, D016BCZ, D016BYZ]
D01797Z-D017BYZHDR and LDR brachytherapy of peripheral nerves [includes codes D01797Z, D01798Z, D01799Z, D0179BZ, D0179CZ, D0179YZ, D017B7Z, D017B8Z, D017B9Z, D017BBZ, D017BCZ, D017BYZ]
D71097Z-D710BYZHDR and LDR brachytherapy of bone marrow [includes codes D71097Z, D71098Z, D71099Z, D7109BZ, D7109CZ, D7109YZ, D710B7Z, D710B8Z, D710B9Z, D710BBZ, D710BCZ, D710BYZ]
D71197Z-D711BYZHDR and LDR brachytherapy of thymus [includes codes D71197Z, D71198Z, D71199Z, D7119BZ, D7119CZ, D7119YZ, D711B7Z, D711B8Z, D711B9Z, D711BBZ, D711BCZ, D711BYZ]
D71297Z-D712BYZHDR and LDR brachytherapy of spleen [includes codes D71297Z, D71298Z, D71299Z, D7129BZ, D7129CZ, D7129YZ, D712B7Z, D712B8Z, D712B9Z, D712BBZ, D712BCZ, D712BYZ]
D71497Z- D714BYZHDR and LDR brachytherapy of axillary lymphatics [includes codes D71497Z, D71498Z, D71499Z, D7149BZ, D7149CZ, D7149YZ, D714B7Z, D714B8Z, D714B9Z, D714BBZ, D714BCZ, D714BYZ]
D71597Z-D715BYZHDR and LDR brachytherapy of thorax lymphatics [includes codes D71597Z, D71598Z, D71599Z, D7159BZ, D7159CZ, D7159YZ, D715B7Z, D715B8Z, D715B9Z, D715BBZ, D715BCZ, D715BYZ]
D71697Z-D716BYZHDR and LDR brachytherapy of abdomen lymphatics [includes codes D71697Z, D71698Z, D71699Z, D7169BZ, D7169CZ, D7169YZ, D716B7Z, D716B8Z, D716B9Z, D716BBZ, D716BCZ, D716BYZ]
D71797Z-D717BYZHDR and LDR brachytherapy of pelvis lymphatics [includes codes D71797Z, D71798Z, D71799Z, D7179BZ, D7179CZ, D7179YZ, D717B7Z, D717B8Z, D717B9Z, D717BBZ, D717BCZ, D717BYZ]
DD1197Z-DD11BYZHDR and LDR brachytherapy of stomach [includes codes DD1197Z, DD1198Z, DD1199Z, DD119BZ, DD119CZ, DD119YZ, DD11B7Z, DD11B8Z, DD11B9Z, DD11BBZ, DD11BCZ, DD11BYZ]
DD1297Z-DD12BYZHDR and LDR brachytherapy of duodenum [includes codes DD1297Z, DD1298Z, DD1299Z, DD129BZ, DD129CZ, DD129YZ, DD12B7Z, DD12B8Z, DD12B9Z, DD12BBZ, DD12BCZ, DD12BYZ]
DD1397Z-DD13BYZHDR and LDR brachytherapy of jejunum [includes codes DD1397Z, DD1398Z, DD1399Z, DD139BZ, DD139CZ, DD139YZ, DD13B7Z, DD13B8Z, DD13B9Z, DD13BBZ, DD13BCZ, DD13BYZ]
DD1497Z-DD14BYZHDR and LDR brachytherapy of ileum [includes codes DD1497Z, DD1498Z, DD1499Z, DD149BZ, DD149CZ, DD149YZ, DD14B7Z, DD14B8Z, DD14B9Z, DD14BBZ, DD14BCZ, DD14BYZ]
DD1597Z-DD15BYZHDR and LDR brachytherapy of colon [includes codes DD1597Z, DD1598Z, DD1599Z, DD159BZ, DD159CZ, DD159YZ, DD15B7Z, DD15B8Z, DD15B9Z, DD15BBZ, DD15BCZ, DD15BYZ]
DD1797Z-DD17BYZHDR and LDR brachytherapy of rectum [includes codes DD1797Z, DD1798Z, DD1799Z, DD179BZ, DD179CZ, DD179YZ, DD17B7Z, DD17B8Z, DD17B9Z, DD17BBZ, DD17BCZ, DD17BYZ]
DF1097Z-DF10BYZHDR and LDR brachytherapy of liver [includes codes DF1097Z, DF1098Z, DF1099Z, DF109BZ, DF109CZ, DF109YZ, DF10B7Z, DF10B8Z, DF10B9Z, DF10BBZ, DF10BCZ, DF10BYZ]
DF1197Z-DF11BYZHDR and LDR brachytherapy of gallbladder [includes codes DF1197Z, DF1198Z, DF1199Z, DF119BZ, DF119CZ, DF119YZ, DF11B7Z, DF11B8Z, DF11B9Z, DF11BBZ, DF11BCZ, DF11BYZ]
DF1397Z-DF13BYZHDR and LDR brachytherapy of pancreas [includes codes DF1397Z, DF1398Z, DF1399Z, DF139BZ, DF139CZ, DF139YZ, DF13B7Z, DF13B8Z, DF13B9Z, DF13BBZ, DF13BCZ, DF13BYZ]
DG1097Z-DG10BYZHDR and LDR brachytherapy of pituitary gland [includes codes DG1097Z, DG1098Z, DG1099Z, DG109BZ, DG109CZ, DG109YZ, DG10B7Z, DG10B8Z, DG10B9Z, DG10BBZ, DG10BCZ, DG10BYZ]
DG1197Z-DG11BYZHDR and LDR brachytherapy of pineal body [includes codes DG1197Z, DG1198Z, DG1199Z, DG119BZ, DG119CZ, DG119YZ, DG11B7Z, DG11B8Z, DG11B9Z, DG11BBZ, DG11BCZ, DG11BYZ]
DG1297Z-DG12BYZHDR and LDR brachytherapy of adrenal glands [includes codes DG1297Z, DG1298Z, DG1299Z, DG129BZ, DG129CZ, DG129YZ, DG12B7Z, DG12B8Z, DG12B9Z, DG12BBZ, DG12BCZ, DG12BYZ]
DG1497Z-DG14BYZHDR and LDR brachytherapy of parathyroid glands [includes codes DG1497Z, DG1498Z, DG1499Z, DG149BZ, DG149CZ, DG149YZ, DG14B7Z, DG14B8Z, DG14B9Z, DG14BBZ, DG14BCZ, DG14BYZ]
DG1597Z-DG15BYZHDR and LDR brachytherapy of thyroid [includes codes DG1597Z, DG1598Z, DG1599Z, DG159BZ, DG159CZ, DG159YZ, DG15B7Z, DG15B8Z, DG15B9Z, DG15BBZ, DG15BCZ, DG15BYZ]
DT1097Z-DT10BYZHDR and LDR brachytherapy of kidney [includes codes DT1097Z, DT1098Z, DT1099Z, DT109BZ, DT109CZ, DT109YZ, DT10B7Z, DT10B8Z, DT10B9Z, DT10BBZ, DT10BCZ, DT10BYZ]
DT1197Z-DT11BYZHDR and LDR brachytherapy of ureter [includes codes DT1197Z, DT1198Z, DT1199Z, DT119BZ, DT119CZ, DT119YZ, DT11B7Z, DT11B8Z, DT11B9Z, DT11BBZ, DT11BCZ, DT11BYZ]
DT1297Z-DT12BYZHDR and LDR brachytherapy of bladder [includes codes DT1297Z, DT1298Z, DT1299Z, DT129BZ, DT129CZ, DT129YZ, DT12B7Z, DT12B8Z, DT12B9Z, DT12BBZ, DT12BCZ, DT12BYZ]
DT1397Z-DT13BYZHDR and LDR brachytherapy of urethra [includes codes DT1397Z, DT1398Z, DT1399Z, DT139BZ, DT139CZ, DT139YZ, DT13B7Z, DT13B8Z, DT13B9Z, DT13BBZ, DT13BCZ, DT13BYZ]
DU1097Z-DU10BYZHDR and LDR brachytherapy of ovary [includes codes DU1097Z, DU1098Z, DU1099Z, DU109BZ, DU109CZ, DU109YZ, DU10B7Z, DU10B8Z, DU10B9Z, DU10BBZ, DU10BCZ, DU10BYZ]
DV1197Z-DV11BYZHDR and LDR brachytherapy of testis [includes codes DV1197Z, DV1198Z, DV1199Z, DV119BZ, DV119CZ, DV119YZ, DV11B7Z, DV11B8Z, DV11B9Z, DV11BBZ, DV11BCZ, DV11BYZ]
  
ICD-10 Diagnosis[For dates of service on or after10/01/2015]
 All diagnoses
  
References

Peer Reviewed Publications:

  1. Arthur DW, Vicini FA, Kuske RR, et al. Accelerated partial breast irradiation: an updated report from the American Brachytherapy Society. Brachytherapy 2003; 2(2):124-130.
  2. Aumont-le Guilcher MA, Prevost B, Sunyach MP, et al. High-Dose-Rate Brachytherapy for Non-Small-Cell Lung Carcinoma: A Retrospective Study of 226 Patients. Int J Radiat Oncol Biol Phys. 2010; 79(4):1112-1116.
  3. Bellon JR, Katz A, Taghian A. Hematology/Oncology of North America. Radiation therapy for breast cancer. Hematol Oncol Clin North Am. 2006; 20(2):239-257.
  4. Benitez PR, Chen PY, Vicini FA, et al. Partial breast irradiation in breast conserving therapy by way of interstitial brachytherapy. Am J Surg. 2004; 188(4):355-364.
  5. Benitez PR, Keisch ME, Vicini F, et al. Five-year results: the initial clinical trial of MammoSite balloon brachytherapy for partial breast irradiation in early-stage breast cancer. Am J Surg. 2007; 194(4):456-462.
  6. Bradley KA, Petereit DG. Radiation therapy for gynecologic malignancies. Hematol Oncol Clin N Am. 2006; 20(2):347-361.
  7. Cuttino LW, Keisch M, Jenrette, JM, et al. Multi-institutional experience using the MammoSite radiation therapy system in the treatment of early-stage breast cancer: 2-year results. Int J Radiat Oncol Biol Phys. 2008; 71(1):107-114.
  8. Dagnault A, Ebacher A, Vigneault E, Boucher S. Retrospective study of 81 patients treated with brachytherapy for endobronchial primary tumor or metastasis. Brachytherapy. 2010; 9(3)243-247.
  9. D'Amico AV, Moran BJ, Braccioforte MH, et al. Risk of death from prostate cancer after brachytherapy alone or with radiation, androgen suppression therapy, or both in men with high-risk disease. J Clin Oncol. 2009; 27(24):3923-3928.
  10. Demanes DJ, Brandt D, Schour L, Hill DR. Excellent results from high dose rate brachytherapy and external beam for prostate cancer are not improved by androgen deprivation. Am J Clin Oncol. 2009; 32(4):342-347.
  11. Dickler A, Puthawala MY, Thropay JP, et al. Prospective multi-center trial utilizing electronic brachytherapy for the treatment of endometrial cancer. Radiat Oncol. 2010; 5:67.
  12. Dooley WC, Thropay JP, Schreiber, GJ, et al. Use of electronic brachytherapy to deliver postsurgical adjuvant radiation therapy for endometrial cancer: a retrospective multicenter study. Onco Targets Ther. 2010; 3:197-203.
  13. Dziewirski W, Rutkowski P, Nowecki ZI, et al. Surgery combined with intraoperative brachytherapy in the treatment of retroperitoneal sarcomas. Ann Surg Oncol. 2006; 13(2):245-252.
  14. Finger PT, Chin KJ, Duvall G; Palladium-103 for Choroidal Melanoma Study Group. Palladium-103 ophthalmic plaque radiation therapy for choroidal melanoma: 400 treated patients. Ophthalmology. 2009; 116(4):790-796.
  15. Frobe A, Jones G, Jasik B, et al. Intraluminal brachytherapy in the management of squamous carcinoma of the esophagus. Dis Esophagus. 2009; 22(6):513-518.
  16. Galale RM, Martinez A, Mate T, et al. Long-term outcome by risk factors using conformal high-dose-rate brachytherapy (HDR-BT) boost with or without neoadjuvant androgen suppression for localized prostate cancer. Int J Radiat Oncol Biol Phys. 2004; 58(4):1048-1055.
  17. Hoskin PJ, Motohashi K, Bownes P, et al. High dose rate brachytherapy in combination with external beam radiotherapy in the radical treatment of prostate cancer: initial results of a randomised phase three trial. Radiother Oncol. 2007; 84(2):114-120.
  18. Hoskin PJ, Rojas AM, Bownes PJ, et al. Randomised trial of external beam radiotherapy alone or combined with high-dose-rate brachytherapy boost for localised prostate cancer. Radiother Oncol. 2012; 103(2):217-222.
  19. Keisch M, Vicini F, Kuske R et al. Initial clinical experience with the MammoSite breast brachytherapy applicator in women with early stage breast cancer treated with breast conserving therapy. Int J Radiat Oncol Biol Phys. 2003; 55(2):289-293.
  20. Kestin LL, Martinez AA, Stromberg JS et al. Matched-pair analysis of conformal high-dose-rate brachytherapy boost versus external-beam radiation therapy alone for locally advanced prostate cancer. J Clin Oncol. 2000; 18(15):2869-2880.
  21. Khan AJ, Vicini FA, Beitsch P, et al. Local control, toxicity, and cosmesis in women >70 years enrolled in the American Society of Breast Surgeons accelerated partial breast irradiation registry trial. Int J Radiat Oncol Biol Phys. 2012; 84(2):323-330.
  22. King TA, Bolton JS, Kuske RR, et al. Long term results of wide field brachytherapy as the sole method of radiation therapy after segmental mastectomy for T(is, 1,2) breast cancer. Am J Surg. 2000; 180(4):299-304.
  23. Koukourakis G, Kelekis N, Armonis V, Kouloulias V. Brachytherapy for prostate cancer: a systematic review. Adv Urol. 2009:327945.
  24. Lawton CA, Yan Y, Lee WR, et al. Long-term results of an RTOG Phase II trial (00-19) of external-beam radiation therapy combined with permanent source brachytherapy for intermediate-risk clinically localized adenocarcinoma of the prostate. Int J Radiat Oncol Biol Phys. 2012; 82(5):e795-e801.
  25. Martinez A, Gonzalez J, Spencer W, et al. Conformal high dose rate brachytherapy improves biochemical control and causes specific survival in patients with prostate cancer and poor prognostic factors. J Urol. 2003; 169(3):974-980.
  26. Mehta VK, Algan O, Griem KL, et al. Experience with an electronic brachytherapy technique for intracavitary accelerated partial breast irradiation. Am J Clin Oncol. 2010; 33(4):327-335.
  27. Melia M, Moy CS, Reynolds SM, et al.; Collaborative Ocular Melanoma Study-Quality of Life Study Group. Quality of life after iodine 125 brachytherapy vs. enucleation for choroidal melanoma: 5-year results from the Collaborative Ocular Melanoma Study: COMS QOLS Report No. 3.Arch Ophthalmol. 2006; 124(2):226-238.
  28. Nelson JC, Beitsch PD, Vicini FA, et al. Four-year clinical update from the American Society of Breast Surgeons Mammosite brachytherapy trial. Am J Surg. 2009; 198(1):83-91.
  29. Patel RR, Arthur DW. Hematology/Oncology of North America. The emergence of advanced brachytherapy techniques for common malignancies. Hematol Oncol Clin North Am. 2006; 20(1):97-118.
  30. Polgar C, Fodor J, Major T, et al. Breast-conserving treatment with partial or whole breast irradiation for low-risk invasive breast carcinoma: 5-year results of a randomized trial. Int J Radiat Oncol Biol Phys. 2007; 69(3):694-705.
  31. Polgar C, Major T, Fodor J, et al. Accelerated partial-breast irradiation using high-dose-rate interstitial brachytherapy: 12-year update of a prospective clinical study. Radiother Oncol. 2010; 94(3):274-279.
  32. Polgar C, Sulyok Z, Fodor J, et al. Sole brachytherapy of the tumor bed after conservative surgery for T1 breast cancer: five year results of a phase I-II study and initial findings of a randomized phase III trial. J Surg Oncol. 2002; 80(3):121-128.
  33. Polgar C, Van Limbergen E, Potter R, et al.; GEC-ESTRO breast cancer working group. Patient selection for accelerated partial-breast irradiation (APBI) after breast-conserving surgery: recommendations of the Groupe Europeen de Curietherapie-European Society for Therapeutic Radiology and Oncology (GEC-ESTRO) breast cancer working group based on clinical evidence (2009). Radiother Oncol. 2010; 94(3):264-273.
  34. Rivard MJ, Davis SD, DeWerd LA, et al. Calculated and measured brachytherapy dosimetry parameters in water for the Xoft Axxent X-Ray Source: an electronic brachytherapy source. Med Phys. 2006 (11):4020-4032.
  35. Shah C et al: .Outcome after ipsilateral breast tumor recurrence in patients who receive accelerated partial breast irradiation. Cancer. 2012, 118(17):4126-4131. 
  36. Shinohara ET, Guo M, Mitra N, Metz JM. Brachytherapy in the treatment of cholangiocarcinoma. Int J Rad Oncol Biol Phys. 2010; 78(3):722-728.
  37. Smith GL, Xu Y, Buchholz TA, et al. Association between treatment with brachytherapy vs whole-breast irradiation and subsequent mastectomy, complications, and survival among older women with invasive breast cancer. JAMA. 2012; 307(17):1827-1837.
  38. Taira AV, Merrick GS, Galbreath RW, et al. Natural history of clinically staged low- and intermediate-risk prostate cancer treated with monotherapeutic permanent interstitial brachytherapy. Int J Radiat Oncol Biol Phys. 2010; 76(2):349-354.
  39. Truong MT. Hematology/Oncology Clinics of North America. Current role of radiation therapy in the management of malignant brain tumors. Hematol Oncol Clin North Am. 2006; 20(2):431-453.
  40. Ung YC, Yu E, Falkson C, et.al. The role of high-dose-rate brachytherapy in the palliation of symptoms in patients with non-small-cell lung cancer: a systematic review. Brachytherapy. 2006; 5(3):189-202.
  41. Vicini F, Shah C, Wilkinson BJ, et al. Should ductal carcinoma-in-situ (DCIS) be removed from the ASTRO Consensus Panel Cautionary Group for off-protocol use of accelerated partial breast irradiation (APBI)? A pooled analysis of outcomes for 300 patients with DCIS treated with APBI. Ann Surg Oncol. 2013; 20(4):1275-1281.
  42. Vicini FA, Beitsch PD, Quiet CA, et al. First analysis of patient demographics, technical reproducibility, cosmesis, and early toxicity. Results of the American Society of Breast Surgeons MammoSite breast brachytherapy registry trial. Cancer. 2005; 104(6):1138-1148.
  43. Vicini FA, Kestin L, Chen P, et al. Limited field radiation therapy in the management of early stage breast cancer. J Natl Cancer Inst. 2003; 95(16):1205-1211.
  44. Vicini FA, Vargas C, Edmundson G, et al. The role of high dose rate brachytherapy in locally advanced prostate cancer. Semin Radiat Oncol. 2003; 13(2):98-108.
  45. Wilkinson JB, Beitsch PD, Shah C, et al. Evaluation of Current Consensus Statement Recommendations for Accelerated Partial Breast Irradiation: A Pooled Analysis of William Beaumont Hospital and American Society of Breast Surgeon MammoSite Registry Trial Data. Int J Radiat Oncol Biol Phys. 2013; 85(5):1179-1185.
  46. Zannis V, Beitsch P, Vicini F, et al. Descriptions and outcomes of insertion techniques of a breast brachytherapy balloon catheter in 1403 patients enrolled in the American Society of Breast Surgeons MammoSite breast brachytherapy registry trial. Am J Surg. 2005; 190(4):530-538.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Brachytherapy Society. Breast Cancer. Available at: http://www.americanbrachytherapy.org/resources/brachyapps.cfm. Accessed on March 27, 2014.
  2. American College of Radiology (ACR) and the American Society for Therapeutic Radiation and Oncology (ASTRO) Practice Guidelines & Technical Standards. Available at: http://www.acr.org/Quality-Safety/Standards-Guidelines/Practice-Guidelines-by-Modality/Radiation-Oncology.  Accessed on April 14, 2013.
    • ACR–ASTRO Practice guideline for the performance of high-dose-rate brachytherapy (2010)
    • ACR–ASTRO Practice guideline for the performance of low-dose-rate brachytherapy (2010)
    • ACR–ASTRO Practice guideline for transperineal permanent brachytherapy of prostate cancer (2010)
  3. American Society of Breast Surgeons. Consensus statement for accelerated partial breast irradiation. Revised October 7, 2008. Available at: http://www.breastsurgeons.org/statements/APBI_statement_revised_100708.pdf.  Accessed on March 27, 2014.
  4. American Urological Association. Prostate Cancer. Reviewed and validated 2011. Available at: http://www.auanet.org/education/guidelines/prostate-cancer.cfm. Accessed on March 27, 2014.
  5. Beriwal S, Demanes DJ, Erickson B, et al.; American Brachytherapy Society. American Brachytherapy Society consensus guidelines for interstitial brachytherapy for vaginal cancer. Brachytherapy. 2012; 11(1):68-75.
  6. Blue Cross Blue Shield Association. Comparative evaluation of radiation treatments for clinically localized prostate cancer: an update. Health Technology Assessment. 2010; 24(9).
  7. Blue Cross Blue Shield Association. Brachytherapy for accelerated partial breast irradiation after breast-conserving surgery for early stage breast cancer. TEC Assessment. 2002; 17(18).
  8. Collaborative Ocular Melanoma Study (COMS) Group. The COMS randomized trial of iodine 125 brachytherapy for choroidal melanoma: Twelve-year mortality rate and prognostic factors: COMS report No.28. Arch Ophthalmol. 2006; 124(12):1684-1693.
  9. Collaborative Ocular Melanoma Study Group.Incidence of cataract and outcomes after cataract surgery in the first 5 years after iodine 125 brachytherapy in the Collaborative Ocular Melanoma Study: COMS Report No. 27. Ophthalmology. 2007; 114(7):1363-1371.
  10. Davis BJ, Horwitz EM, Lee WR, et al  American Brachytherapy Society consensus guidelines for transrectal ultrasound-guided permanent prostate brachytherapy. Brachytherapy. 2012; 11:6-19.
  11. Erickson BA, Demanes DJ, Ibbott GS, et al. American Society for Radiation Oncology (ASTRO) and American College of Radiology (ACR) practice guideline for the performance of high-dose-rate brachytherapy. Int J Radiat Oncol Biol Phys. 2011; 79(3):641-6490
  12. Nag S, Cano ER, Demanes DJ, et al.; American Brachythreapy Society. The American Brachytherapy Society recommendations for high-dose-rate brachytherapy for head-and-neck carcinoma. Int J Radiat Oncol Biol Phys. 2001; 50(5):1190-1198.
  13. Nag S, Quivey JM, Earle JD, et al.; American Brachytherapy Society. The American Brachytherapy Society recommendations for brachytherapy of uveal melanomas. Int J Radiation Oncol Biol Phys. 2003; 56(2):544-555.
  14. National Comprehensive Cancer Network® (NCCN). Clinical Practice Guidelines in Oncology™. © 2014 National Comprehensive Cancer Network, Inc. For additional information: http://www.nccn.org. Accessed on March 27, 2014.
    • Basal Cell and Squamous Cell Skin Cancers. V.2.2014. Revised February 20, 2014.
    • Breast Cancer. V.2.2014. March 6, 2014.
    • Head and Neck Cancers. V.1.2013. Revised May 29, 2013.
    • Hepatobiliary Cancer. V.1.2014. Revised February 28, 2014.
    • Non-Small Cell Lung Cancer. V.3.2014. Revised January 24, 2014.
    • Penile Cancer. V.1.2014. Revised October 8, 2013.
    • Prostate Cancer. V.2.2014. Revised April 1, 2014.
    • Soft Tissue Sarcoma. V.2.2014. Revised March 19, 2014.
    • Uterine Neoplasms. V.1.2014. Revised November 27, 2013.
  15. Park CC, Yom SS, Podgorsak MB, et al; Electronic Brachytherapy Working Group. American Society for Therapeutic Radiology and Oncology (ASTRO) Emerging Technology Committee report on electronic brachytherapy. Int J Radiat Oncol Biol Phys. 2010; 76(4):963-972.
  16. Reveiz L, Rueda JR, Cardona AF. Palliative endobronchial brachytherapy for non-small cell lung cancer. Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.: CD004284.
  17. Rosenthal SA, Bittner NH, Beyer DC, et al.; American Society for Radiation Oncology; American College of Radiology. American Society for Radiation Oncology (ASTRO) and American College of Radiology (ACR) practice guideline for the transperineal permanent brachytherapy of prostate cancer. Int J Radiat Oncol Biol Phys. 2011; 79(2):335-341.
  18. Shaitelman SF, Vicini FA, Beitsch P, et al. Five-year outcome of patients classified using the American Society for Radiation Oncology consensus statement guidelines for the application of accelerated partial breast irradiation: an analysis of patients treated on the American Society of Breast Surgeons MammoSite Registry Trial. Cancer. 2010; 116(20):4677-4685.
  19. Smith BJ, Arthur DW, Buchholz, et al. Accelerated partial breast irradiation consensus statement from the American Society for Radiation Oncology (ASTRO). J Am Coll Surg. 2009; 209(2):269-277.
  20. U.S. Food and Drug Administration 510(k) Premarket Notification Database. Axxent Electronic Brachytherapy System. No. K050843. Rockville, MD: FDA. Available at: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm. Accessed on March 27, 2014.
  21. Wang X, Liu R, Ma B, et al. High dose rate versus low dose rate intracavity brachytherapy for locally advanced uterine cervix cancer. Cochrane Database Syst Rev. 2010; Issue 7. Art. No.:CD007563.
  22. Yamada Y, Rogers L, Demanes DJ, et al.; American Brachytherapy Society. American Brachytherapy Society consensus guidelines for high-dose-rate prostate brachytherapy. Brachytherapy. 2012; 11(1):20-32.
Websites for Additional Information

American Cancer Society. Available at:  http://www.cancer.org/. Accessed on March 27, 2014.

  1. National Cancer Institute (NCI). Available at http://www.cancer.gov/. Accessed on March 27, 2014.
    • Breast Cancer Treatment Physician Data Query (PDQ®): Treatment. Last modified March 20, 2014.
    • Intraocular (Eye) Melanoma Treatment (PDQ). Last modified November 9, 2012.
    • Penile Cancer Treatment (PDQ). Last modified March 7, 2014. 
    • Prostate Cancer Treatment (PDQ). Last modified February 14, 2014.
    • Radiation therapy for cancer: Fact Sheet. Reviewed June 30, 2010.
Index

Axxent Electronic Brachytherapy System
Breast Brachytherapy
Contura
Electronic Brachytherapy
High Dose Rate Temporary Brachytherapy
Implant Radiation
Internal Radiation
Interstitial Seed Brachytherapy
MammoSite Radiation Therapy Systems
ProstRcision
Savi

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Document History

Status

Date

Action

Revised05/15/2014Medical Policy & Technology Assessment Committee (MPTAC) review.
Revised05/14/2014Hematology/Oncology Subcommittee review. Removed life expectancy criteria for intermediate-risk prostate cancer. Updated Rationale, References, and Websites.
Revised05/09/2013MPTAC review.
Revised05/08/2013Hematology/Oncology Subcommittee review. Clarified medically necessary criterion for high-risk prostate cancer – removed "after definitive therapy." Added "or without" to medically necessary criteria for treatment of intermediate-risk prostate cancer. Updated Rationale, References, and Websites.
Revised11/08/2012MPTAC review.
Revised11/07/2012Hematology/Oncology Subcommittee review. Updated Rationale, References, and Websites. Updated Coding section with 01/01/2013 HCPCS changes.
Revised11/17/2011MPTAC review.
Revised11/16/2011Hematology/Oncology Subcommittee review. Removed "with or without EBRT" from LDR prostate cancer criterion. Revised prostate cancer criteria. Updated Rationale, References, and Websites.
Reviewed05/19/2011MPTAC review.
Reviewed05/18/2011Hematology/Oncology Subcommittee review. Updated Rationale, References, and Websites.
 04/01/2011Updated Coding section with 04/01/2011 HCPCS changes; removed S2270 deleted 03/31/2011.
Revised11/18/2010MPTAC review.
Revised11/17/2010Hematology/Oncology Subcommittee review. Removed positive nodes; DCIS and invasive breast cancer as medically necessary breast cancer indications. Added age criterion to breast cancer indication. Added medically necessary indication for cholangiocarcionoma. Clarified medically necessary indication for prostate cancer. Updated Rationale, References, and Websites. Updated Coding section to include 01/01/2011 CPT changes.
Reviewed08/19/2010MPTAC review.
Reviewed07/01/2010Hematology/Oncology Subcommittee review. Reviewed criteria for breast cancer. Web Sites updated.
Revised05/13/2010MPTAC review.
Revised05/12/2010Hematology/Oncology Subcommittee review. Reformatted criteria. Clarified medically necessary criteria for breast cancer. Added medically necessary indications for retinoblastoma and penile carcinoma. Rationale, references, websites and coding updated.
Revised05/21/2009MPTAC review.
Revised05/20/2009Hematology/Oncology Subcommittee review. Additional medically necessary indications for esophageal, head and neck cancers. Rationale, references, websites and coding updated.
 01/01/2009Updated Coding section with 01/01/2009 CPT changes; removed 77781, 77782, 77783, 77784 deleted 12/31/2008.
 10/01/2008Updated Coding section with 10/01/2008 ICD-9 and HCPCS changes.
Revised05/15/2008MPTAC review.
Revised05/14/2008Hematology/Oncology Subcommittee review. Title changed to "Brachytherapy for Oncologic Indications". Added medically necessary criteria for ocular melanoma, vulvar/vaginal carcinoma and soft tissue sarcoma. Updated rationale, coding, references and websites.
 01/01/2008Updated Coding section with 01/01/2008 CPT changes.  The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." This change was approved at the November 29, 2007 MPTAC meeting.
Revised05/17/2007MPTAC review.
Revised05/16/2007Hematology/Oncology Subcommittee review. Electronic brachytherapy added to list of investigational and not medically necessary. Updated rationale, references and coding. Added new CPT code 0182T.
Reviewed12/07/2006MPTAC review.
Reviewed12/06/2006Hematology/Oncology Subcommittee review. References updated. Coding updated; removed CPT 55859 deleted 12/31/06.
 01/01/2007Updated Coding section with 01/01/2007 CPT/HCPCS changes; removed CPT 55859 deleted 12/31/2006, and HCPCS G0256, G0261 deleted 12/31/2003.
Revised12/01/2005MPTAC review.
Revised11/30/2005Hematology/Oncology Subcommittee review. Added medically necessary position statement for uterine, cervical and endometrial cancers. Added all other tumors not listed are investigational and not medically necessary.
Reviewed09/22/2005MPTAC review.  Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.
Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem, Inc.

 

10/27/2004

RAD.00014Brachytherapy for Breast Cancer and Prostate Cancer Treatment
WellPoint Health Networks, Inc.

04/28/2005

4.11.04Breast Brachytherapy
 

06/24/2004

2.11.13Radioactive Seed Implantation for Prostate Cancer
 

06/24/2004

4.11.05Endobronchial Brachytherapy