Prior authorization expected for listed radiation procedure codes

Prior authorization is implied for the CPT/HCPCS codes listed as covered (e.g., 77402-77417, 77436-77439, 77767-77772, 77778) when those services are billed for the CPB-covered indications; selection criteria in the policy must be met before treatment is considered medically necessary.

• Covered CPT ranges: 77402-77417, 77436-77439, 77767-77772, 77778 (see coding section).
• Ensure documentation supports that the member meets the condition-specific selection criteria in the policy (e.g., keloid excision within 7 days, osteoarthritis age and prior therapy requirements, high-risk features for HO).

No explicit prior-authorization process stated for experimental indications

The policy text includes clinical series and background but does not specify additional or separate prior-authorization rules or a distinct prior authorization process tied to specific experimental indications described in the background.

• Case series (e.g., single-fraction 25 Gy SBRT for cardiac VT) are described in background without stating a separate PA requirement or defined PA pathway for those experimental uses.

Policy does not define additional CPT/HCPCS PA-trigger codes

Across the policy background and history there are no explicit, additional lists of CPT/HCPCS codes that trigger prior authorization beyond the covered and not-covered code listings provided in the coding section.

• Policy coding tables list covered and not-covered CPT codes but do not add separate PA-trigger code lists in the narrative background or policy history.

Stepwise treatment required before radiation for osteoarthritis

For osteoarthritis, radiation therapy is considered only after a stepwise trial of therapies: inadequate response to non-pharmacologic therapies, then inadequate response/intolerance/contraindication to pharmacologic therapies, and after orthopedic surgical evaluation that deems the patient medically inoperable for joint replacement.

• Document inadequate response to non-pharmacologic therapies (e.g., physical therapy, exercise).
• Document inadequate response, intolerance, or contraindication to pharmacologic therapies (e.g., topical/systemic analgesics, intra-articular glucocorticoids).
• Include orthopedic surgeon consultation indicating disease advanced enough for joint replacement but patient is medically inoperable.

Conservative therapies must be tried before low-dose radiotherapy for OA

Background and guidance indicate low-dose radiotherapy (LDRT) for osteoarthritis is intended for patients refractory to conventional conservative therapies; providers should document trials of exercise, physical therapy, and NSAIDs (or intolerance) before LDRT is considered.

• Record conservative therapies attempted and duration (e.g., exercise, physical therapy, NSAIDs).
• Document rationale for selecting LDRT (joint selection, impact on quality of life, prior therapy response).

Keloid excision + postoperative radiation: document CPB 0031 indications and treatment within 7 days

When postoperative radiation is given for keloids, documentation must show the excision met medical necessity criteria for keloid removal per CPB 0031 and that radiation was delivered within the policy-specified window (within 7 days after excision).

• Reference CPB 0031 to demonstrate medically necessary indication for keloid excision.
• Document timing of radiation relative to excision (treatment within 7 days per policy).
• Include radiation regimen details (e.g., HDR brachytherapy schedules cited in background such as 12 Gy in 4 fractions or 18 Gy in 6 fractions when applicable).

Osteoarthritis documentation: age and failed therapies required

For osteoarthritis claims, include documentation that the member is at least 60 years old and that prior non-pharmacologic and pharmacologic therapies failed or were not tolerated; also include the orthopedic surgeon evaluation stating the patient is medically inoperable for joint replacement.

• Member age (≥ 60 years).
• Records of non-pharmacologic therapy attempts and outcomes.
• Records of pharmacologic therapy trials, intolerances, or contraindications.
• Orthopedic surgeon consultation findings and operative candidacy determination.

HO prophylaxis: document high-risk features to support medical necessity

When radiation is used for heterotopic ossification (HO) prophylaxis, document the presence of high-risk features (for example: prior HO, ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis, spinal stenosis, unlimited pre-op hip motion, or head injury) to support medical necessity.

• List and document high-risk features present in the patient.
• Include surgical context and timing of prophylactic radiation relative to surgery as applicable.

Document treatment regimens, dose schemes, and follow-up schedules in the record

Medical records should include treatment reports specifying the regimen, dose/fractionation scheme, and planned follow-up schedule; background examples (HDR brachytherapy fractionation, electron RT schemes, LDRT fraction sizes) are referenced and should be recorded in the chart when used.

• Specify radiation modality, total dose, fractions, and timing (e.g., HDR brachytherapy 12 Gy in 4 fractions; electron RT schemes 21 Gy in 7 fractions or 30 Gy in 10 fractions; LDRT typically 0.5 Gy/fraction).
• Document follow-up plan and outcome assessments used in cited series (e.g., follow-up intervals used in Guix et al.).

Policy history provided — no extra documentation obligations in history section

Policy history and review links are provided in the document header and history section, but these sections do not impose additional clinical documentation requirements beyond those already stated.

• Review dates and links are for reference; they do not change the documentation expectations in the clinical criteria.

Coding-related denial risk for not-covered ablative/SBRT CPT codes

Claims submitted with CPT codes listed as not covered for the CPB indications (for example, ablative radiotherapy codes 77373 and 77435 used for cardiac arrhythmia) are at risk of denial when those experimental/unproven indications are billed.

• Do not bill ablative/SBRT CPTs 77373 or 77435 for cardiac arrhythmia indications described in this CPB.
• Ensure coding matches the modality and indication supported by the policy's covered code list and clinical criteria.

Background case-series do not constitute PA or denial triggers

Several background sections and series describe clinical experience without stating specific prior-authorization or denial triggers; these background-only descriptions do not themselves create authorization rules.

• Treat background reports (case series, observational data) as clinical context rather than PA policy language.
• Rely on the policy's coverage criteria and coding tables to determine medical necessity and appropriate billing.