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CIGNA HEALTHCARE COVERAGE POSITION Subject Brachytherapy of the Prostate Table of Contents Coverage Position............................................... 1 General Background ........................................... 2 Coding/Billing Information ................................... 7 References .......................................................... 9 Revised Date ........................... 10/15/2006 Original Effective Date ........... 10/15/2005 Coverage Position Number ............. 0419 Hyperlink to Related Coverage Positions Cryoablation for Prostate Cancer Gene-Based Testing for Prostate Cancer Screening, Detection and Disease Monitoring Inpatient Stays for Radiation Therapy Intensity-Modulated Radiation Therapy (IMRT) Intraoperative Radiation Therapy Laparoscopic Radical Prostatectomy Neutron Beam Therapy Prostate Saturation Biopsy Prostate-Specific Antigen (PSA) Screening for Prostate Cancer Proton Beam Therapy for Prostate Cancer Stereotactic Radiosurgery Transrectal Ultrasound (TRUS) Tumor Markers for Diagnosis and Management of Cancer INSTRUCTIONS FOR USE Coverage Positions are intended to supplement certain standard CIGNA HealthCare benefit plans. Please note, the terms of a participant’s particular benefit plan document [Group Service Agreement (GSA), Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which these Coverage Positions are based. For example, a participant’s benefit plan document may contain a specific exclusion related to a topic addressed in a Coverage Position. In the event of a conflict, a participant’s benefit plan document always supercedes the information in the Coverage Positions. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Coverage determinations in each specific instance require consideration of 1) the terms of the applicable group benefit plan document in effect on the date of service; 2) any applicable laws/regulations; 3) any relevant collateral source materials including Coverage Positions and; 4) the specific facts of the particular situation. Coverage Positions relate exclusively to the administration of health benefit plans. Coverage Positions are not recommendations for treatment and should never be used as treatment guidelines. ©2006 CIGNA Health Corporation Coverage Position CIGNA HealthCare covers brachytherapy for the treatment of prostate cancer as medically necessary when the cancer is clinically confined to the prostate and when any ONE of the following criteria is met: • • • The administration method will be low-dose treatment, using permanently implanted seeds as monotherapy, for patients with low-risk cancers. The therapy is administered in conjunction with external beam radiation and/or neoadjuvant androgen ablation for patients with intermediate-risk cancers. The therapy is used to deliver a high-dose treatment using a temporary implant technique followed by external beam radiation and androgen ablation for patients with high-risk cancers. Page 1 of 11 Coverage Position Number: 0419 CIGNA HealthCare does not cover brachytherapy for palliative treatment of the prostate because it is considered experimental, investigational or unproven. General Background Prostate cancer is the most common cancer in males in the United States. It is anticipated that approximately 234,460 men in the U.S. will be diagnosed with prostate cancer in 2006. When this cancer is caught in its early stages, while many tumors are low-grade and slow-growing, survival rates are excellent, and cure rates can be as high as 98% in some cases. Some evidence has suggested that heredity may play a role in the development of prostate cancer. Men with a family history are at higher risk of developing this disease. Having one family member with prostate cancer doubles a man’s own risk, and having three family members poses an 11-fold risk for this disease (National Cancer Institute [NCI], 2006). Current screening protocols for the early detection of prostate cancer include the monitoring of prostate specific antigen (PSA) serum levels and digital rectal examinations. PSA levels can rise as a result of prostate cancer or may become increased as a result of benign conditions such as prostatic hyperplasia (BPH), acute prostatitis, or following prostate biopsy. A PSA level of 4.0 nanograms/milliliter (ng/mL) or less is considered normal; however, 15% of men with this “normal” PSA will have prostate cancer, and 2% will have high-grade cancer (National Comprehensive Cancer Network [NCCN], 2005). When prostate cancer is suspected, a transrectal, ultrasound-guided prostate biopsy is performed to confirm the diagnosis. If the biopsy confirms the presence of cancer, then histological staging and scoring of the cancer is also obtained. Radiological studies (e.g., bone scan or computerized tomography [CT]) may also be conducted to determine if the cancer has metastasized to other organs. By utilizing this information (i.e., PSA levels, tumor stage and Gleason scoring) patients can be stratified into categories associated with different probabilities of achieving a cure (Carver, 2006; NCCN, 2005; Kawashima, 2005). Tumor (T) Staging and Gleason (G) Scoring: T staging and G scores provide guidance for the physician, the extended treatment team and the patient in determining the best clinical course of care. There are two systems that may be used for the staging of prostate cancer, the Jewett system (stages A through D) and the American Joint Commission on Cancer (AJCC), which includes a tumor (T), node (N) and metastasis (M) staging (NCI, 2006). During this staging and grading process a tumor is analyzed to determine how well or poorly its cells are organized and, as a result of this cellular structure, the tumor’s probability of metastasizing to other sites. By utilizing this information, it may be determined that extensive radiation therapy is needed, a modified or radical surgery and/or adjuvant androgen ablation therapy is needed to achieve the best treatment outcome (NCCN, 2005). A (T) staging of: • T1-a, b, or c to T2-a, b, or c indicates that the tumor is confined to the prostate • T 3 or 4 indicates that the cancer has spread beyond the prostate As part of the grading process, it will also be determined if the lymph nodes are involved or if the cancer has spread to other sites (e.g., the bones). This grading is referred to as a node (N) score: • N 0 indicates that regional nodes are cancer free • N1, 2, or 3 indicates that regional nodes are involved To complete the staging scale of the tumor, it must be determined if the cancer has metastasized (M) to other organs or body systems. • M0 indicates no distant metastasis • M1 indicates distant metastasis • M1a indicates spread to non-regional lymph node(s) • M1b indicates spread to the bone(s) • M1c indicates spread to other site(s) with or without bone disease Page 2 of 11 Coverage Position Number: 0419 Gleason (G) Scoring: This histopatholgical grading system is considered to be the optimal method of grading, because it has been clearly shown to be of great prognostic value. The following G indicators may be assigned to a tumor: • GX a grade cannot be assessed • G1 well differentiated (slight anaplasia) (Gleason 2-4) • G2 moderately differentiated or undifferentiated (marked anaplasia) (Gleason 5-6) • G3-4 poorly differentiated or undifferentiated (marked anaplasia) (Gleason 7-10) The Jewett staging system: This system was first described in 1975 and has since been modified to include: • Stage A is clinically undetectable tumor confined to the prostate gland and is an incidental finding at the time of prostate surgery. o Substage A1: well-differentiated with focal involvement, usually left untreated o Substage A2: moderately or poorly differentiated or involves multiple foci in the gland • Stage B is tumor confined to the prostate gland. o Substage B0: nonpalpable, PSA-detected o Substage B1: single nodule in one lobe of the prostate o Substage B2: more extensive involvement of one lobe or involvement of both lobes • Stage C is tumor clinically localized to the periprostatic area but extending through the prostate’s capsule; seminal vesicles may be involved. o Substage C1: clinical extracapsular extension o Substage C2: extracapsular tumor producing bladder outlet or urethral obstruction • Stage D is metastatic disease. o Substage D0: clinically localized disease (prostate only) but persistently elevated enzymatic serum acid phosphatase titers o Substage D1: regional lymph nodes only o Substage D2: distant lymph nodes, metastases to bone or visceral organs o Substage D3: D2 prosate cancer patients who relapsed after adequate endocrine therapy (NCI, 2006). A patient’s age, coexisting medical problems and the aggressiveness of the tumor (i.e., T stage and G score) may dictate the course of treatment and its timing. Primary treatment options for prostate cancer include surgery, radiotherapy, and hormonal manipulation. Treatment may occur immediately upon diagnosis, or a watchful waiting approach may be taken. A radical prostatectomy and external beam radiation therapy (EBRT) continue to be widely used as definitive therapies for localized cancer. However, these same therapies carry the risk of post-operative rectal or urinary complications and impotency (Kawashima, 2005; NCI, 2006). In an attempt to decrease the side effects of these therapies, alternative methods of delivering radiation (i.e., brachytherapy) to the prostate have been proposed. Brachytherapy includes the use of radioactive implants that deliver low-dose (LD) or high-dose (HD) therapy as an adjunct or boost to EBRT. In select patients, brachytherapy as a monotherapy may eliminate the need for EBRT in the treatment of prostate cancer. Brachytherapy Brachytherapy is one method that may be used to deliver high radiation doses to nearby tumor tissue, while sparing normal tissues that are located distal to the site of radiation. The goal of this treatment is to prevent the recurrence of any residual cancer with minimal adverse outcomes. The implantation of radioactive agents takes specialized training by the surgeon, the radiation oncologist and the imaging staff. There are several determining factors that impact the treatment course used to deliver radiotherapy: the location of the tumor; the size and shape of the tumor; the type of tumor, genetic factors and hormonal receptors of the tumor (American Cancer Society [ACS], 2006; American Society for Therapeutic Radiology and Oncology [ASTRO], 2006; Carver, 2006; Chue, 2005; NCI, 2006). When brachytherapy is used for the treatment of prostate cancer, transrectal ultrasonography is used to guide the placement of steel-encapsulated 125Iodine (125I) or 103 Palladium (103Pd) seeds throughout the prostate gland. With 125I seeds, the total treatment doses are relatively high (e.g., 145 gray [Gy]); Page 3 of 11 Coverage Position Number: 0419 however, dose rates are relatively low. The dose rate declines during the actual treatment period as the iodine within the implanted seed decays (i.e., the half-life of 125I is 59.6 days). Because of these factors, it is difficult to speculate regarding the predicted biologic effects of permanent prostate implants versus fractionated EBRT regimens. One drawback of permanent implantation is the potential for underdosing a portion(s) of the tumor. This can possibly occur if seeds are misplaced during the procedure, or they may shift after placement. Asymmetric radiation emissions are observed around cylindrical seeds, which may cause underdosing of some regions. The clinical reports to date suggest that prostate tumors with favorable prognosis are equally well controlled with interstitial implants and fractionated EBRT. The use of prophylactic radiation of clinically or pathologically uninvolved pelvic lymph nodes does not appear to improve overall survival or prostate cancer-specific survival (Chue, 2005; NCI, 2006). Several specialty societies have published patient selection criteria for use in determining the appropriate application of brachytherapy. Patient selection is based on a confirmed diagnosis of cancer that is clinically confined to the prostate and/or surrounding tissues (i.e., stage I, II, and III). The presence of metastases should be radiologically ruled out and patient co-morbidities may also influence the treatment regimen (American Brachytherapy Society [ABS], 2005; American Urological Association [AUA] and NCI, 2006; NCCN, 2005; Radiation Society of North America [RSNA], 2005). Literature Review Numerous studies have been conducted regarding the usage of brachytherapy; most have been retrospective, small in size (ranging from 50 to 2000+), and nonrandomized. According to the NCI, a retrospective review of 999 patients treated with megavoltage irradiation showed cause-specific survival rates to be significantly different at 10 years by T-stage: T1 (79%), T2 (66%), T3 (55%), and T4 (22%). Long-term results with radiation therapy are dependent on stage. Patients considered poor medical candidates for radical prostatectomy can be treated with acceptably low complications if care is given to the delivery technique (NCI, 2006). Potters et al. (2005) presented the 12-year bio-chemical freedom from recurrence (BFR) outcomes from their eight-year (1992-2000) study of 1449 consecutive patients treated for clinically localized prostate cancer using brachytherapy with EBRT, neoadjunct hormonal therapy or brachytherapy as a primary source of radiation therapy. Patients with a PSA of 10ng/ml or less, Gleason score of 2-6 and clinical stage T1 to T2a tumors were considered low risk and treated with brachytherapy alone. Patients with PSA greater than 10ng/ml, Gleason score 7-10 or clinical stage T2b were considered higher risk and were treated with a combination of EBRT and brachytherapy. Seeds were placed using an interstitial gun applicator without fluoroscopy. During the course of this study, prescribed dosing changed, leading to a decrease in the amount of EBRT that was delivered in order to compensate for the radiation amounts already administered using the radioactive seeds. Median follow-up was 82 months, with overall and disease-specific survival at 12 years of 81% and 93%, respectively. The researchers noted that only 20% of this study group actually received a combined treatment protocol of brachytherapy and EBRT. The addition of EBRT may mask a poor dosimetric implant, adding additional toxicity and expense. The role of adjunctive androgen therapy remains controversial. The researchers concluded that these BFR outcomes: 1) continue to remain acceptable, 2) they continue to identify a direct relationship between implant quality as measured by a dose volume of 90% (D90), and 3) when PSA doubling time is less than 12 months in men who experience biochemical failure, aggressive salvage therapy may be required. They also concluded that additional studies are necessary to determine the specific role of hormonal therapy, and specific clinical data and dose modeling standards need to be determined that will improve the efficacy of brachytherapy as a standalone radiation modality. Sathya and colleagues (2005) conducted a randomized, controlled trial to determine if iridium (IM) implants and EBRT were more effective than the standard application of EBRT in the treatment of locally advanced prostate cancer. One hundred and four patients were randomly assigned into two groups (i.e., group one receiving IM and EBRT and group two receiving EBRT-alone). All patients underwent a pelvic lymphadenectomy as a staging procedure and if nodes were determined to be positive, they were excluded from the study. Patients began EBRT approximately three to four weeks after the pelvic lymphadenectomy. Patients randomly assigned to receive brachytherapy had cannula implantation at the time of the lymphadenectomy once the nodes were cleared after frozen section results were obtained. These cannulas were then afterloaded with IM being delivered over a total of 48 hours before removal. Patients returned in two weeks and EBRT was initiated. Biochemical or clinical failure (BCF) defined as Page 4 of 11 Coverage Position Number: 0419 PSA failure, clinical failure, or death as a result of prostate cancer, were the primary outcome measures for this study. The researchers noted that PSA failure was the earliest event noted in 28 patients (12 in the implant-plus-EBRT group and 16 in the EBRT-alone group). At the end of 24 months, all patients were required to undergo a post-radiation biopsy; however, only 87 (84%) of the 104 patients complied. In the implant-plus group, 10 (24%) of 42 patients had positive results, while 23 (51%) of the 45 patients in the EBRT-alone group had positive biopsies. The clinical pathologist who read these biopsies was blinded to the treatment protocol of each patient. During the course of this study, 17 patients died: 10 in the implant and EBRT group, and seven in the EBRT-alone group. At five years, the probability of survival was 94% in the implant and EBRT group and 92% in the EBRT-only group. With the medial follow-up of 8.2 years, the researchers concluded that there was no difference in survival detected between these groups. They also concluded that superior results were obtained with the use of combination therapy versus EBRT-alone, as evidenced by the post-treatment biopsy results. Sathya and colleagues also determined that additional studies are needed to compare this treatment with 3D-CRT and/or IMRT, in which dose escalation is possible. In a Hayes literature review of 2005, which included two randomized studies, several case series and review articles, the authors concluded that the use of brachytherapy as a treatment with curative intent for clinically localized prostate cancer was favorable for use in patients with stage T1 or T2, PSA ≤ 10ng/ml, and a Gleason score of ≤ 6. They also concluded that there is insufficient evidence that supports the use of brachytherapy as a salvage treatment for recurrence or when primary treatment failure occurs. Polascik et al. (1998) conducted a retrospective historical comparison of actuarial PSA progression-free survival after prostatectomy versus brachytherapy as a monotherapy. After seven years he reported a 97.8% survival after prostatectomy versus 79% after brachytherapy. This study suggests that surgery versus brachytherapy has a better outcome. This study was nonrandomized; a present surgical series was used for comparison and standard definitions of biochemical control were not used. In studies where patients were stratified according to risk categories, outcome rates were better in favorable-risk patients compared with those at intermediate or unfavorable risk. Favorable risk was defined as stage T1 or T2, pretreatment PSA of less than or equal to 10 ng/ml and Gleason scores of less than or equal to six (Walsh, 2002; Merrick, 2005). The NCI and the Radiation Therapy Oncology Group (RTOG) are recruiting patients to participate in a phase III randomized trial to compare the effectiveness of interstitial brachytherapy with or without external beam radiation therapy in treating patients who have prostate cancer. This study will involve 1520 patients and accrual is expected to take five years (NCI, 2006). NCI is also conducting a phase III randomized trial comparing intermittent versus continuous androgen suppression for patients with PSA progression in the clinical absence of distant metastases following radiotherapy. This active study involves 1340 patients; however, outcomes are not available at this time (NCI, 2005). Professional Societies/Organizations The American Brachytherapy Society (ABS, 2005): The ABS inclusion criteria for low-dose brachytherapy: • Life expectancy greater than five years • Clinical stage: T1b-T2c and selected T3 • Gleason score 2-10 • PSA: in almost all cases, a PSA less than 50ng/ml • No pathological evidence of pelvic lymph node involvement • No distant metastases Patient selection for monotherapy: • Clinical stage T1b-T2b and Gleason score ≤ to 6 and PSA ≤ 10ng/ml • Select higher risk patients • Salvage of select radiation therapy failures Patient selection for boost therapy: • Clinical stage T2c or greater and/or Gleason score ≥ 7 and/or PSA > 10ng/ml Page 5 of 11 Coverage Position Number: 0419 Inadequate information exists to recommend supplemental XRT based on perineural invasion, percent positive biopsies and/or MRI-detected extracapsular penetration (Merrick, 2005). The American Urological Association (AUA), and the National Cancer Institute (NCI) recognize the use of brachytherapy only for a select group of patients—those with a prostate volume of less than 60 ml and who have early-stage prostate cancer (i.e., T1 or T2 tumor, a Gleason grade lower than 7, and a PSA level below 10ng/ml). Poor candidates for brachytherapy include men who have had a transurethral resection of the prostate (TURP) and patients with advanced cancer, high-grade tumors, or very large prostate glands. The ABS also includes patients with a life expectancy of five years or less (Nag, 1999; NCI, 2005). The National Comprehensive Cancer Network (NCCN, 2005): Prostate Cancer Guidelines suggest the use of the following in the treatment of prostate cancer: • EBRT ¾ Three dimensional (3D) conformal or IMRT (intensity modulated radiation therapy) techniques should be employed. ¾ Doses of 70-75 Gy in 35-41 fractions to the prostate (± seminal vesicles for part of the therapy) appear to be appropriate for patients with low-risk cancers. ¾ For patients with intermediate- or high-risk disease, doses between 75-80 Gy appear to provide improved PSA-assessed disease control. ¾ Patients with high-risk cancers are candidates for pelvic lymph node irradiation and the addition of neoadjuvant ± adjuvant androgen ablation therapy. ¾ If target prostate tumor volume (PTV) margins are reduced, such as for doses above 75 Gy, extra attention to daily prostate localization, with techniques such as ultrasound implanted fiducials, or an endorectal balloon, is indicated. • Brachytherapy ¾ Permanent brachytherapy as monotherapy is indicated for patients with low-risk cancers (i.e., T1-T2a and G score 2-6 and PSA less than 10ng/mL). ¾ For intermediate-risk cancers (i.e., T2b-T2c or G score 7 or PSA 10-20 ng/mL) consider combining brachytherapy with EBRT (40-50 Gy) ± neoadjuvant androgen ablation. ¾ Patients with high-risk cancers (i.e., T3a or G score 8-10 or PSA greater than 20 ng/mL) are generally considered poor candidates for permanent brachytherapy; however, with the addition of EBRT and androgen ablation, it may be effective in select patients. ¾ Patients with a large prostate (> 60 grams [gm]), symptoms of bladder outlet obstruction (IPSS score > 15), or a previous transurethral resection of the prostate (TURP) are not ideal candidates because of increased risk of urinary morbidity. Neoadjuvant androgen ablation may be used to shrink the prostate to an acceptable size. ¾ Post-implant dosimetry should be performed to document the quality of the implant. ¾ The recommended prescribed doses for monotherapy are 145 Gy for 125-Iodine and 125 Gy for 103-Palladium. The corresponding boost dose after 40-50 Gy EBRT is 110 Gy and 100 Gy, respectively. The National Cancer Institute (NCI, 2005) standard treatment options for patients diagnosed with T1 or T2A prostate cancer are as follows: • Stage I (AJCC-T1a, N0, M0, G1 [Gleason score 2-4] or Jewett stage A1): ¾ careful observation without further immediate treatment in selected patients ¾ radical prostatectomy, usually with pelvic lymphadenectomy. Postsurgical radiation therapy may be appropriate for patients who are found to have capsular penetration or seminal vesicle invasion or when PSA levels are detectable more than three weeks after surgery. ¾ external beam radiation therapy ¾ interstitial implantation of radioisotopes (i.e., 125-I, palladium, iridium) using a transperineal technique with ultrasound or CT guidance. Retropubic freehand implantation with 125-I has been associated with an increased local failure and complication rate. This technique is rarely used at this time. • Stage II (AJCC-T1a-c, N0, any G or Jewett stage A2 or B1 or B2): Page 6 of 11 Coverage Position Number: 0419 radical prostatectomy, usually with pelvic lymphadenectomy. Postsurgical radiation therapy may be appropriate for patients who are found to have capsular penetration or seminal vesicle invasion or when PSA levels are detectable more than three weeks after surgery. ¾ careful observation ¾ external-beam radiation therapy ¾ external beam radiation therapy plus androgen-suppression therapy ¾ interstitial implantation of radioisotopes (i.e., 125-I, palladium, iridium) using a transperineal technique with ultrasound or CT guidance. Retropubic freehand implantation with 125-I has been associated with an increased local failure and complication rate. This technique is rarely done at this time. Stage II (AJCC-T2, N0 any G or Jewett stage B1 or B2): ¾ radical prostatectomy, usually with pelvic lymphadenectomy. Postsurgical radiation therapy may be appropriate for patients who are found to have capsular penetration or seminal vesicle invasion or when PSA levels are detectable more than three weeks after surgery. ¾ external-beam radiation therapy ¾ careful observation ¾ interstitial implantation of radioisotopes (i.e., 125-I, palladium, iridium) using a transperineal technique with ultrasound or CT guidance. Retropubic freehand implantation with 125-I has been associated with an increased local failure and complication rate. This technique is rarely done at this time. Stage III: ¾ external beam radiation therapy ¾ external beam radiation therapy plus hormonal therapy ¾ hormonal manipulations (i.e., orchiectomy or luteinizing hormone-releasing hormone [LHRH] agonist) ¾ radical prostatectomy, usually with pelvic lymphadenectomy. Postsurgical radiation therapy may be appropriate for patients who are found to have capsular penetration or seminal vesicle invasion or when PSA levels are detectable more than three weeks after surgery. ¾ careful observation Stage IV: ¾ hormonal manipulation (e.g., orchiectomy, LHRH agonists, leuprolide plus flutamide, or estrogens) ¾ external beam radiation ¾ palliative radiation therapy ¾ palliative surgery (i.e., TURP) ¾ careful observation (in selected patients) ¾ • • • Radiation Society of North America (RSNA, 2005): The RSNA reports that the long-term results that are available for up to 10-12 years at some institutions show that ultra-sound guided radioactive implantation by very experienced physicians is highly effective in controlling prostate cancer and has essentially the same result as surgery or EBRT for appropriately selected low-risk prostate cancer patients. High-dose brachytherapy (HDR) was developed to supplement EBRT for patients with high-risk prostate cancer and has been proven to be effective. Use of HDR as a sole radiation treatment for lowrisk patients is still in the developmental stages. Summary Brachytherapy in the treatment of prostate cancer has been determined to be safe and efficacious when delivered conservatively; implanted using ultrasound or computerized tomography guidance; and administered when the cancer is confined to the prostate. Studies are underway that will determine if lowdose versus high-dose therapy will be as effective, while reducing the potential side effects of radiation treatment. Brachytherapy is not generally used as a palliative treatment in patients with advanced cancer, highgrade tumors, or in patients with a life-expectancy of five years or less. Coding/Billing Information Page 7 of 11 Coverage Position Number: 0419 Note: This list of codes may not be all-inclusive. Covered when medically necessary: CPT®* Codes 55859 76873 77263 77280 77285 77290 77295 77300 77326 77327 77328 77336 77370 77470 77761 77762 77763 77776 77777 77778 77781 77782 77783 77784 77789 77790 HCPCS Codes C1715 Description Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy Ultrasound, transrectal; prostate volume study for brachytherapy treatment planning (separate procedure) Therapeutic radiology treatment planning; complex Therapeutic radiology simulation-aided field setting; simple Therapeutic radiology simulation-aided field setting; intermediate Therapeutic radiology simulation-aided field setting; complex Therapeutic radiology simulation-aided field setting; three-dimensional Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non-ionizing radiation surface and depth dose, as required during course of treatment, only when prescribed by the treating physician Brachytherapy isodose plan; simple (calculation made from single plane, one to four sources/ribbon application, remote afterloading brachytherapy, 1 to 8 sources) Brachytherapy isodose plan; intermediate (multiplane dosage calculations, application involving 5 to 10 sources/ribbons, remote afterloading brachytherapy, 9 to 12 sources) Brachytherapy isodose plan; complex (multiplane isodose plan, volume implant calculations, over 10 sources/ribbons used, special spatial reconstruction, remote afterloading brachytherapy, over 12 sources) Continuing medical physics consultation, including assessment of treatment parameters, quality assurance of dose delivery, and review of patient treatment documentation in support of the radiation oncologist, reported per week of therapy Special medical radiation physics consultation Special treatment procedure (e.g., total body irradiation, hemibody radiation, per oral, endocavity or intraoperative cone irradiation Intracavitary radiation source application; simple Intracavitary radiation source application; intermediate Intracavitary radiation source application; complex Interstitial radiation source application; simple Interstitial radiation source application; intermediate Interstitial radiation source application; complex Remote afterloading high intensity brachytherapy; 1-4 source positions or catheters Remote afterloading high intensity brachytherapy; 5-8 source positions or catheters Remote afterloading high intensity brachytherapy; 9-12 source positions or catheters Remote afterloading high intensity brachytherapy; over 12 source positions or catheters Surface application of radiation source Supervision, handling, loading of radiation source Description Brachytherapy needle Page 8 of 11 Coverage Position Number: 0419 C1716 C1717 C1718 C1719 C1720 C1728 C2616 C2633 C2634 C2635 C2636 C2637 C9725 ICD-9-CM Diagnosis Codes 185 233.4 Brachytherapy source, gold 198 Brachytherapy seed, high dose rate iridium 192 Brachytherapy source, iodine 125 Brachytherapy source, non-high dose rate iridium 192 Brachytherapy source, palladium 103 Catheter, brachytherapy seed administration Brachytherapy source, yttrium-90, per source Brachytherapy source, cesium-131, per source Brachytherapy source, high-activity, Iodine-125, greater than 1.01 mCi (NIST), per source Brachytherapy source, high-activity, Paladium-103, greater than 2.2 mCi (NIST), per source Brachytherapy linear source, paladium 103, per 1 mm Brachytherapy source, ytterbium-169, per source Placement of endorectal intracavitary applicator for high intensity brachytherapy Description Malignant neoplasm of prostate Carcinoma in situ of prostate *Current Procedural Terminology (CPT®) ©2005 American Medical Association: Chicago, IL. References 1. American Cancer Society (ACS). How is prostate cancer treated? Updated Jul 2006. Accessed Aug 2006. Available at URL address: http://www.cancer.org/docroot/CRI/content/CRI_2_4_4X_How_is_prostate_cancer_treated_36.as p?sitearea= 2. American Cancer Society (ACS). How is radiation given? Updated Jul 2005. Accessed Aug 2006. Available at URL address: http://www.cancer.org/docroot/ETO/content/ETO_1_4X_How_is_radiation_given.asp? 3. American Society for Therapeutic Radiology and Oncology (ASTRO). Radiation therapy for prostate cancer. Updated 2006. Accessed Aug 2006. Available at URL address: http://www.astro.org/pdf/Patient%20Information/astroprostatebrochure2.pdf 4. Carver BS, Dalbagni G, Sheinfeld J. (authors). Malignant Tumors of the Urogenital Tract. In: Rakel: Conn’s Current Therapy 2006. 58th ed. St. Louis, MO: W.B. Saunders Co.; 2006. 5. Catton C, Milosevic M, Warde P, Bayley A, Crook J, Bristow R, Gospodarowicz M. Recurrent prostate cancer following external beam radiotherapy: follow-up strategies and management. Urologic Clinics of North America. Nov 2003;30(4). 6. Chue I. (author). Chapter 13: Principles of radiation oncology. In: DeVita VT, Hellman S, Rosenberg S. CANCER Principles & Practices of Oncology. Vol 1.Philadelphia, PA: Lippincott, Williams & Wilkins; McGraw-Hill Companies, Inc.;2005. 7. Crook J. Prostate seed implant patient information. Updated 2004. Accessed Sept 2005. Available at URL address http://www.brachy4u.ca/Brachy4U/site/overviewmain.html Page 9 of 11 Coverage Position Number: 0419 8. Delongchamps NB, Singh A, Haas GP. The role of prevalence in the diagnosis of prostate cancer. Cancer Control. 2006;13(3):158-68. 9. HAYES Medical Technology Assessment™. Transperineal ultrasound-guided brachytherapy for early-stage prostate cancer. Lansdale, PA: HAYES, Inc., ©2005 Winifred S. Hayes, Inc. September 2005. 10. 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