Coding and Billing Guidance

Prior authorization and coding implications: Radiation delivery CPT codes (77401-77417, 77767-77772, 77778) are covered when the policy's selection/medical necessity criteria are met (e.g., keloid excision with RT within 7 days, heterotopic ossification prevention in high-risk persons, Ledderhose disease after failure of conservative therapy). When billing, include applicable CPT/HCPCS and ICD-10 codes and document the treatment intent (adjunctive post-op for keloid, prophylaxis for heterotopic ossification, or treatment for Ledderhose disease).

• Covered CPT ranges (when criteria met): 77401-77417, 77767-77772, 77778
• ICD-10 examples supporting coverage when criteria met: L91.0 (keloid), M72.2 (plantar fascial fibromatosis), M45.x (ankylosing spondylitis), S06.x (intracranial injury) for HO risk factors
• Keloid: radiation as adjunctive therapy within 7 days post-excision when keloid removal is medically necessary per CPB 0031

Prior Authorization — Case-by-Case Review

Prior authorization: case-by-case review is likely for novel or nonstandard indications (for example, radiotherapy for drug-resistant epilepsy or SBRT for cardiac arrhythmia); consult Aetna Clinical Policy Bulletin and plan provisions for any required prior authorization processes.

• Novel/nonstandard indications (e.g., cardiac arrhythmia ablation with radiotherapy, TRASER device use) will generally require individual review
• Consult applicable plan prior authorization requirements and the Aetna Clinical Policy Bulletin notes linked in the policy

Prior Authorization Requirements

Prior authorization requirements: Providers must follow the member's plan benefits and any Clinical Policy Bulletin instructions. Prior authorization may be required per plan; when in doubt, obtain pre-service review documentation to substantiate medical necessity.

• Refer to Aetna Clinical Policy Bulletin and the member's plan provisions for specific prior authorization processes
• Obtain pre-service review when required by the plan to avoid claim denials

Experimental / Not Covered Techniques

Experimental/investigational exclusions: Use of the TRASER device and ablative radiotherapy for cardiac arrhythmia are considered experimental/investigational and are not covered because effectiveness has not been established.

• TRASER (Total Reflection Amplification of Spontaneous Emission Radiation) — experimental/investigational for nasal telangiectasias
• Ablative radiotherapy for cardiac arrhythmia (e.g., SBRT for VT) — experimental/investigational; associated CPT codes for SBRT (77373, 77435) are not covered for this indication

Clinical Documentation Requirements

Documentation expectations: Clinical documentation must support the diagnosis, prior conservative treatments tried, and treatment intent. For Ledderhose disease and other benign indications, document failure of conventional therapies and rationale for radiotherapy (including prior injections, medications, or conservative measures).

• Document diagnosis with appropriate ICD-10 code and clinical findings
• Document conservative therapies attempted (e.g., tamoxifen, verapamil, steroid injections, shoe inserts, shockwave therapy) and their failure or intolerance
• For keloid RT, document timing of excision and that RT is delivered within 7 days post-excision as adjunctive therapy

Ledderhose (Plantar Fibromatosis) — Provider Actions

Ledderhose-specific provider actions: Radiation therapy may be medically necessary for plantar fibromatosis when conventional treatments have failed. Expect documentation of prior conservative measures and clear treatment intent; RT dosing/fields should be consistent with published practices (e.g., en face electrons, typical dose schemes noted in literature).

• Indication: Plantar fascial fibromatosis (Ledderhose disease) — consider RT after failure of conservative measures
• Document prior conservative and operative treatments and rationale for RT; record dose/fractionation and treatment field details in chart

Conservative Measures, Documentation & Denial Risk

Conservative measures and denial risk: Conservative treatments should be attempted for Ledderhose and other benign conditions prior to radiotherapy. There are no explicit denial triggers listed in this portion of the document beyond the listed experimental/investigational exclusions; however, failure to document prior conservative care or to meet the policy's selection criteria may increase risk of denial.

• Conservative measures examples: steroid injections, tamoxifen, verapamil, shoe inserts, extracorporeal shockwave therapy
• No explicit insurer-specific prior-authorization triggers are described in this document segment; follow plan rules and bulletin guidance
• Lack of adequate documentation of prior therapies and medical necessity is a common reason for claim denial

Administrative Notes

Administrative/provider notes: Preserve policy history and follow plan benefits and Clinical Policy Bulletin guidance for any operational questions. This section does not list additional explicit denial triggers beyond those noted above.

• Policy effective date: 2001-08-14; last review 07/27/2023; next review 06/13/2024
• Refer to Clinical Policy Bulletin Notes and plan-specific administrative procedures for submission and appeals