CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy Electronic Brachytherapy for Nonmelanoma Skin Cancer

This policy addresses coverage of electronic (high-dose-rate) skin-surface brachytherapy for treatment of nonmelanoma skin cancer (NMSC) for Blue Cross Blue Shield - Rhode Island commercial and Medicare Advantage products, including coverage stance and applicable codes.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Electronic Brachytherapy for Nonmelanoma Skin Cancer

Policy CodePolicy N/A

Change TypeClarified (no material change)

Effective DateJan 1, 2023

Next Review Date

Key ActionRefer to the member's Benefit Booklet / Evidence of Coverage / Subscriber Agreement for benefit determination.

SourceLink

POLICY UPDATE CHANGES

Policy updated most recently 08/02/2023 with no clinical policy statement changes indicated in the document.

1CPT codes explicitly listed as not covered

1ICD-10 diagnosis code range referenced

0Covered indications listed

Coverage Summary

This policy addresses coverage of electronic (high-dose-rate) skin-surface brachytherapy for the treatment of nonmelanoma skin cancer (NMSC). The policy scope covers Blue Cross Blue Shield - Rhode Island Commercial and Medicare Advantage products and explicitly lists applicable CPT and ICD-10 codes. Electronic brachytherapy is considered not covered / not medically necessary because the evidence is insufficient to determine the effects of the technology on health outcomes.

Policy metadata

Effective Date01 01 2023

Last Review08/02/2023

Coverage StanceElectronic brachytherapy for treatment of nonmelanoma skin cancer is considered not covered / not medically necessary (evidence insufficient to determine effects on health outcomes).

ScopePolicy addresses electronic (high-dose-rate) skin-surface brachytherapy for nonmelanoma skin cancer (NMSC) for Blue Cross Blue Shield - Rhode Island commercial and Medicare Advantage products, including coverage stance and applicable codes.

Medical‑Necessity Criteria

Policy Statement

Coverage determination:

Electronic brachytherapy for the treatment of nonmelanoma skin cancer is considered not covered because the evidence is insufficient to determine the effects of the technology on health outcomes.

For Commercial Products: Electronic brachytherapy for the treatment of nonmelanoma skin cancer is considered not medically necessary as the evidence is insufficient to determine the effects of the technology on health outcomes.

Not Covered / Experimental

Rationale for noncoverage: The available evidence for electronic brachytherapy consists of systematic reviews, prospective cohort studies, and case series; no randomized controlled trials comparing electronic brachytherapy with alternative treatments were identified. Thus, the evidence is insufficient to determine the effects on health outcomes.

A 2016 systematic review of case series reported local control rates ranging from 83% to 100% with recurrence rates from 0% to 17% (most studies reported <5% recurrence). A 2019 meta-analysis reported that brachytherapy cosmesis grades and 5-year local control rates were comparable to Mohs micrographic surgery and conventional excision, but confidence in these findings is limited by study design and conduct limitations in the available nonrandomized studies.

Electronic brachytherapy: A form of radiotherapy delivered locally using a miniaturized electronic X-ray source and surface applicators (molds) to deliver uniform radiation to superficial skin lesions without radioisotopes.

Nonmelanoma skin cancer (NMSC): Includes basal cell carcinoma and squamous cell carcinoma and other less common skin malignancies; ICD-10 range C44.00–C44.99 referenced.

Coding

Not covered / Not medically necessary CPT code(s)CPTNot Covered

0394T

High dose rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, when performed

Applicable ICD-10 diagnosis code range for noncoverageICD-10

C44.00-C44.99

Malignant neoplasm of skin (nonmelanoma skin cancer) - diagnosis code range listed with CPT 0394T

Provider Actions

Documentation Required

Reference benefit documents

Benefits may vary by contract; providers must refer to the member's Benefit Booklet / Evidence of Coverage / Subscriber Agreement for benefit determination.

Denial Risk

Claims for electronic brachytherapy with listed codes

Claims submitted with CPT 0394T for ICD-10 diagnoses C44.00-C44.99 are considered not covered for Medicare Advantage and not medically necessary for Commercial Products and may be denied.

0394T
C44.00-C44.99

Background & Evidence

Electronic brachytherapy is a localized high-dose-rate skin-surface radiotherapy technique that uses a miniaturized electronic source with pliable molds or surface applicators to deliver a uniform dose to well-circumscribed, superficial tumors. Advantages described include a shorter treatment schedule, avoidance of radioisotopes, and focused delivery that spares surrounding healthy tissue.

The evidence base includes 2 systematic reviews, prospective cohort studies, and multiple case series reporting local control and recurrence rates, but no randomized controlled trials comparing electronic brachytherapy with surgical approaches or other radiotherapy options have been identified.

Evidence Summary

Performance Metrics

Local control83%-100%

Recurrence0%-17%

Definitions

Electronic brachytherapy: A form of radiotherapy delivered locally using a miniaturized electronic X-ray source and surface applicators (molds) to deliver uniform radiation to superficial skin lesions without radioisotopes.

Nonmelanoma skin cancer (NMSC): Includes basal cell carcinoma and squamous cell carcinoma and other less common skin malignancies; ICD-10 range C44.00–C44.99 referenced.

Revision History

2023-08-02Policy updatedLatest

Policy updated

2023-08-02Clarification (non-material)

Policy updated most recently 08/02/2023 with no clinical policy statement changes indicated in the document (Provider Update October 2023; no material coverage change)

2023-01-01Effective date

Policy effective date established

2019-10Publication

Published in Provider Update (one of prior Provider Updates listed leading up to the 2023 update)