Perirectal Spacer Use During Radiotherapy for Prostate Cancer
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Policy governing coverage of transperineal placement of biodegradable perirectal spacers (e.g., SpaceOAR, Barrigel) for patients receiving radiotherapy for organ-confined prostate cancer for Blue Cross Blue Shield of North Carolina.
A statement that perirectal spacer placement is not medically necessary for individuals undergoing proton beam therapy for prostate cancer was added.
Coverage (medically necessary) for transperineal placement of a biodegradable perirectal spacer for individuals undergoing external beam radiation therapy (IMRT or SBRT) for organ-confined prostate cancer was added.
Description clarified that the hydrogel spacer maintains separation for approximately 3 months and is absorbed by 12 months.
Coverage Criteria for Perirectal Spacer Placement
Medically necessary — External beam RT (IMRT or SBRT)
Covered when ALL of the following are met
Per BCBSNC policy statement: coverage provided when medical criteria and guidelines are met.
Transperineal placement of a biodegradable perirectal spacer (eg, SpaceOAR) is not medically necessary for individuals undergoing proton beam therapy for treatment of prostate cancer.
Use of a perirectal spacer when the policy's coverage criteria are not met is considered investigational. This investigational designation explicitly includes use of a spacer with brachytherapy monotherapy and may result in denial of coverage.
Placement of a transperineal biodegradable perirectal spacer is designated not medically necessary for recipients of proton beam therapy for prostate cancer and therefore is not covered in that context.
Use of a perirectal spacer in conjunction with brachytherapy monotherapy is considered investigational and is not covered.
Applicable Service Codes
| 55874 | Applicable service code listed for perirectal spacer placement |
Provider Actions, Documentation, and Authorization
If records requested, submit complete clinical details and support
When BCBSNC requests records for medical necessity review, include the specific information needed to make the determination and any supporting letters; letters alone are not sufficient documentation unless they contain all required information.
- Provide complete clinical records and any relevant explanatory/support letters
- Ensure supporting letters include all specific information required for medical necessity review
Provide complete medical records and supporting documentation if requested
BCBSNC may request medical records to determine medical necessity; when records are requested include all specific information needed for a medical necessity determination and any supporting letters as appropriate (letters alone are not sufficient).
- Include all specific information needed to make a medical necessity determination
- Letters of support/explanation may be useful but are not sufficient unless they contain all required information
Denial risk: proton beam therapy and non‑covered indications
Requests for perirectal spacer placement for patients receiving proton beam therapy may be denied as not medically necessary; requests outside the coverage criteria (for example use with brachytherapy monotherapy) may be considered investigational and denied.
- Perirectal spacer placement is considered not medically necessary for individuals undergoing proton beam therapy for prostate cancer
- Use when coverage criteria are not met (including brachytherapy monotherapy) is considered investigational and may be denied
Background and Rationale
Prostate cancer ranges from indolent to aggressive disease. External-beam radiation therapy modalities such as IMRT or SBRT are definitive treatment options for organ-confined prostate cancer but carry a risk of acute and late gastrointestinal toxicity because of the rectum’s proximity to the prostate. Perirectal spacers are biodegradable biomaterials placed transperineally to increase separation between the prostate and rectum during radiation, with the goal of reducing rectal dose and associated GI toxicity.
Definitions
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