Clinical UM Guideline
|Subject:||Inpatient Admission for Radiation Therapy for Cervical or Thyroid Cancer|
|Guideline #:||CG-MED-38||Current Effective Date:||04/07/2015|
|Status:||Reviewed||Last Review Date:||02/05/2015|
This document addresses the medical necessity of an inpatient admission for radiation treatment for cervical and thyroid cancer. Radiation implants, also called brachytherapy, may be placed in interstitial or intracavity spaces for the treatment of cervical cancer. Thyroid cancer may be treated with radioactive iodine such as I-131. Individuals are discharged from the hospital after the radiation implants are removed or when the levels of radioactivity are deemed safe and appropriate for discharge.
This document does not address the use of I-131, a radioactive substance when used as a diagnostic tool in an I-131 scan.
An inpatient admission for radiation treatment for cervical or thyroid cancer is considered medically necessary for the period of time the individual's calculated level of radioactivity is greater than the discharge guidelines set by the U.S. Nuclear Regulatory Commission (USNRC, 2002). See Appendix A.
Not Medically Necessary:
An inpatient admission for radiation treatment for cervical cancer or thyroid cancer is considered not medically necessary when the above criteria are not met.
|Goal Length of Stay|
Goal Length of Stay: Generally 1-2 days. The Radiation Safety Department will clear the individual for discharge when the individual emits a safe level of radiation.
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.
|55920||Placement 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|
|57156||Insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy|
|58346||Insertion of Heyman capsules for clinical brachytherapy|
|77470||Special treatment procedure (eg, total body irradiation, hemibody radiation, per oral or endocavitary irradiation)|
|77761||Intracavitary radiation source application; simple|
|77762||Intracavitary radiation source application; intermediate|
|77763||Intracavitary radiation source application; complex|
|77776||Interstitial radiation source application; simple|
|77777||Interstitial radiation source application; intermediate|
|77778||Interstitial radiation source application; complex|
|79005||Radiopharmaceutical therapy, by oral administration|
|A9517||Iodine I-131 sodium iodide capsule(s), therapeutic, per millicurie|
|A9530||Iodine I-131 sodium iodide solution, therapeutic, per millicurie|
|ICD-9 Procedure||[For dates of service prior to 10/01/2015]|
|92.28||Injection or instillation of radioisotopes|
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2015]|
|179||Malignant neoplasm of uterus, part unspecified|
|180.0||Malignant neoplasm of cervix uteri, endocervix|
|180.1||Malignant neoplasm of cervix uteri; exocervix|
|180.8||Malignant neoplasm of cervix uteri; other specified sites of cervix|
|180.9||Malignant neoplasm of cervix uteri; unspecified|
|182.0||Malignant neoplasm of body of uterus; corpus uteri, except isthmus|
|182.1||Malignant neoplasm of body of uterus; isthmus|
|182.8||Malignant neoplasm of other specified sites of body of uterus|
|193||Malignant neoplasm of thyroid gland|
|198.82||Secondary malignant neoplasm of other genital organs|
|233.1||Carcinoma in situ of cervix uteri|
|233.2||Carcinoma in situ of other and unspecified parts of uterus|
|234.8||Carcinoma in situ, other specified sites (thyroid)|
|V10.41||Personal history of malignant neoplasm of cervix uteri|
|V10.42||Personal history of malignant neoplasm of other parts of uterus|
|V10.87||Personal history of malignant neoplasm of thyroid|
|V58.0||Encounter for radiotherapy|
|ICD-10 Procedure||[For dates of service on or after 10/01/2015]|
|0UHC01Z-0UHC81Z||Insertion of radioactive element into cervix [by approach; includes codes 0UHC01Z, 0UHC31Z, 0UHC41Z, 0UHC71Z, 0UHC81Z]|
|CW7GGZZ||Systemic nuclear medicine therapy of thyroid using iodine 131 (I-131)|
|DWY5GDZ||Isotope administration to whole body using iodine 131 (I-131)|
|ICD-10 Diagnosis||[For dates of service on or after 10/01/2015]|
|C53.0-C53.9||Malignant neoplasm of cervix uteri|
|C54.0-C54.9||Malignant neoplasm of corpus uteri|
|C55||Malignant neoplasm of uterus, part unspecified|
|C73||Malignant neoplasm of thyroid gland|
|C79.82||Secondary malignant neoplasm of genital organs|
|D06.0-D06.9||Carcinoma in situ of cervix uteri|
|D07.0||Carcinoma in situ of endometrium|
|D07.39||Carcinoma in situ of other female genital organs|
|D09.3||Carcinoma in situ of thyroid and other endocrine glands|
|Z51.0||Encounter for antineoplastic radiation therapy|
|Z85.41||Personal history of malignant neoplasm of cervix uteri|
|Z85.42||Personal history of malignant neoplasm of other parts of uterus|
|Z85.850||Personal history of malignant neoplasm of thyroid|
Cervical radiation implants, sometimes called brachytherapy, may be administered by loading a surgically placed device into the cervix with radiation material in a form such as capsules. This type of implant is left in place for several days in which time the individual is hospitalized. Another type of procedure for cervical radiation implants is done on an outpatient basis called high-dose rate (HDR) brachytherapy. In this method, the implant remains only an hour or less, and is done weekly repeated three to five times. A third type of treatment involves interstitial implants in which needles are inserted into the cervical tissue around the cancer and loaded with radioactive material. The individual may remain hospitalized until the implants are removed and the individual meets discharge criteria.
Generally, for thyroid cancer, I-131 therapy is done after a total or a partial thyroidectomy. The thyroid absorbs almost all of the body's iodine. I-131 is used to destroy cancer cells that take up iodine and were not removed by surgery and those that have spread beyond the thyroid (American Cancer Society [ACS], 2013). Therapy is given in either liquid or pill form. Dosing of the therapy can be calculated using an empiric or fixed dosing, quantitative dosimetry, or upper bound limits set by blood dosimetry (National Comprehensive Cancer Network® [NCCN®], 2014). The most widely used and the simplest method is the empiric or fixed dose. The individual's dose is determined by the extent of their disease with typical doses within 30-200 mCi (NCCN, 2014). In the past, individuals were routinely hospitalized for I-131 radiation therapy. Hospitalization is no longer routinely required because a change in federal legislation permits the use of much larger doses in ambulatory individuals (NCCN, 2014; U.S. Nuclear Regulatory Commission [USNRC], 2013).
Individuals are encouraged to drink fluids to help the I-131 pass quickly through the body. I-131 is excreted in all body fluids. Therefore, all objects coming into contact with the individual that may be contaminated with sweat, urine, feces, blood or other body fluids are considered radioactive. Within a few days, most of the radiation has been excreted.
According to the U.S. Nuclear Regulatory Commission regulations (2013), individuals treated with various forms of radioactive implants must remain in the hospital until all the implant material has been removed and accounted for. A source count and radiation survey must be done prior to discharge. The radiation survey is calculated according to the maximum exposure rate radiation level at a distance of one meter from the individual. This occurs when total effective dose equivalent to any other individual from exposure to the released individual is not likely to exceed 5mSv (0.5 rem). Local or State regulations may differ from the U.S. Nuclear Regulatory Commission (USNRC, 2013). For safety, the survey requires exposure rate radiation levels be determined in the individual's room and the surrounding area, recorded, and maintained for inspection by the department.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Websites for Additional Information|
Brachytherapy for Cervical Cancer
Interstitial Cervical Radiation
Intracavity Cervical Radiation
Radiation Implant for Cervical Cancer
Radiotherapy for Cervical Cancer
|Reviewed||02/05/2015||Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Description, Coding, References and Websites sections.|
|Reviewed||02/13/2014||MPTAC review. Updated References and Websites sections.|
|Reviewed||02/14/2013||MPTAC review. Updated References and Websites sections.|
|Reviewed||02/16/2012||MPTAC review. Updated References and Websites sections.|
|01/01/2012||Updated Coding section with 01/01/2012 CPT descriptor revisions.|
|Reviewed||02/17/2011||MPTAC review. Updated References and Websites sections. Updated Coding section with 04/01/2011 HCPCS changes; removed S2270 deleted 03/31/2011.|
|10/14/2010||Category changed from CG-RAD-19 to CG-MED-38. Updated Website information.|
|Reviewed||02/25/2010||MPTAC review. References and websites updated.|
|Revised||02/26/2009||MPTAC review. References, websites and coding updated. Clinical indications clarified and Appendix A added. Place of Service Section removed.|
|Reviewed||02/21/2008||MPTAC review. References, websites updated. No change to position.|
|01/01/2008||Updated Coding section with 01/01/2008 CPT changes.|
|New||03/08/2007||MPTAC review. Initial guideline development. Combined CG-RAD-03 Inpatient Admission for I-131 Radiation Treatment for Thyroid Cancer with CG-RAD-17 Radiation Implants for Cervical Cancer Length of Stay. Description, discussion, references and coding updated.|
U.S. Nuclear Regulatory Commission (USNRC). Consolidated guidance about materials licenses. Program-specific guidance about medical use licenses. Final report. NUREG-1556, Vol. 9, Rev 2. Page updated July 24, 2013. Available at: http://www.nrc.gov/reading-rm/doc-collections/nuregs/staff/sr1556/v9/r2/. Accessed on November 24, 2013.
Table U.1 Activities and Dose Rates for Authorizing Patient Release†
|The activity values were computed based on 5 millisieverts (0.5 rem) total effective dose equivalent.|
|If the release is based on the dose rate at 1 meter in Column 2, the licensee must maintain a record as required by 10 CFR 35.75(c), because the measurement includes shielding by tissue. See Item U.3.1, "Records of Release," for information on records.|
|Activity and dose rate time limits are not applicable in this case because of the minimal exposures to members of the public resulting from activities normally administered for diagnostic or therapeutic purposes.|
The millicuric values were calculated using Equations U.2 or U.3 and the physical half-life. The gigabecquerel values were calculated using the millicuric values and the conversion factor from millicuric to gigabecquerels. The dose rate values are calculated using the millicuric values and the exposure rate constants.
In general, the values are rounded to two significant figures; however, values less than 0.37 gigabecquerel (10 millicuries) or 0.1 millisievert (10 millirems) per hour are rounded to one significant figure. Details of the calculations are provided in NUREG-1492.
Although non-byproduct materials are not regulated by NRC, information on non-by product material is included for the convenience of the licensee.
Agreement State regulations may vary. Agreement State licensee should check with their State regulations before using these values.