CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Electronic brachytherapy for nonmelanoma skin cancer

Policy governing coverage of electronic (high-dose-rate) brachytherapy delivered to skin surface lesions for treatment of nonmelanoma skin cancer under Blue Cross Blue Shield - Rhode Island commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyElectronic brachytherapy for nonmelanoma skin cancer

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2017

Next Review Date

Key ActionVerify member benefits and eligibility per the subscriber agreement before submitting claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not medically necessaryCoverage stance (commercial)

1-3MEstimated annual US cases

80-92%Reported 5‑yr control rates

0394TNot medically necessary code

Coverage Criteria

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Not medically necessary: For individuals with nonmelanoma skin cancer who receive electronic brachytherapy, the evidence is insufficient to determine the effects of the technology on health outcomes; therefore the service is considered not medically necessary for Commercial Products.

CPT 0394T (high dose rate electronic brachytherapy, skin surface application) filed with ICD-10 range C44.00-C44.99 is listed as not medically necessary and may be denied.

Electronic brachytherapy for the treatment of nonmelanoma skin cancer is considered not medically necessary for Commercial Products because the evidence is insufficient to determine effects on health outcomes. Claims for CPT 0394T (high dose rate electronic brachytherapy, skin surface application, per fraction) filed with ICD-10 diagnosis codes in the range C44.00–C44.99 are listed as not medically necessary and may be denied.

Provider Actions & Billing Guidance

Prior Authorization

Prior authorization — Prior authorization is not applicable per this policy.

Denial Risk

Denial Risk for CPT 0394T

Denial risk — Claims for CPT 0394T filed with ICD-10 diagnosis range C44.00–C44.99 may be denied as not medically necessary.

Affected code: CPT 0394T — High dose rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, when performed
Affected diagnosis range: ICD-10 C44.00–C44.99

Note

Benefit Verification

Benefit verification — Providers should verify member benefits and eligibility prior to providing services. The member's subscriber agreement, certificate of coverage, and/or employer agreement determine benefits and supersede this policy.

Contact the Blue Cross Blue Shield of Rhode Island provider call center for member-specific benefits and eligibility information
Do not bill members for services determined to be not medically necessary unless the member was informed and provided written agreement to self-pay

Background

Nonmelanoma skin cancers (primarily basal cell and squamous cell carcinoma) are common and frequently treated with surgical excision; when surgery is not feasible or not preferred, radiotherapy is an accepted alternative. Electronic brachytherapy is a localized form of radiotherapy that uses a miniaturized electronic X‑ray source with surface molds or applicators to deliver a uniform, high‑dose‑rate radiation directly to superficial, well‑circumscribed skin tumors over multiple sessions.

This technique can be applied to nonflat surfaces (for example, the nose or ear) using a pliable mold and shielded surface applicator. Potential advantages compared with standard external beam radiotherapy include a shorter treatment schedule and avoidance of radioisotopes or surgical intervention, but current evidence is insufficient to establish its impact on clinical outcomes for nonmelanoma skin cancer.

Definitions

Definition — Electronic brachytherapy

Modality descriptionRadiotherapy delivered locally using a miniaturized electronic X‑ray source rather than a radionuclide-based source.

ApplicatorsUses pliable surface molds or applicators (e.g., silicone or polymethylmethacrylate) fitted to the tumor surface to treat superficial, nonflat lesions such as the nose or ear.

Treatment targetDesigned for well‑circumscribed, superficial skin tumors (nonmelanoma skin cancers).

Radioisotope useDoes not use radionuclides or radioactive sources; the energy is generated by an electronic X‑ray source.

Treatment scheduleDelivered over multiple treatment sessions within a short time period (typically within a month).