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    OpenPayerPolicy UpdatesClinical/Medical PolicyBluecross Idaho Brachytherapy Coverage | OpenPayer
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    CurrentBluecross IdahoPolicy MP 8.01.62

    Electronic Brachytherapy for Nonmelanoma Skin Cancer

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    This policy governs coverage of electronic brachytherapy for nonmelanoma skin cancer, including basal cell carcinoma and squamous cell carcinoma, under Blue Cross of Idaho benefit plans. The treatment is considered investigational, subject to the member-specific benefit plan, applicable law, and related policies.

    Policy Summary
    PayerBluecross Idaho
    PolicyElectronic Brachytherapy for Nonmelanoma Skin Cancer
    Policy CodePolicy N/A
    Change TypeLiterature and reference updateno material coverage change
    Effective DateJul 30, 2026
    Last ReviewJul 30, 2026
    Next Review DateN/A
    Key ActionTreat electronic brachytherapy for nonmelanoma skin cancer as investigational and apply the policy as a basis for denial.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    InvestigationalCoverage determination for electronic brachytherapy
    SCC and BCCPrimary cancer types addressed
    0Controlled comparative trials identified
    Insufficient

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    Evidence for improved net health outcome
    May 27, 2026Literature review cutoff

    Coverage Criteria

    Evidence conclusion

    The evidence is insufficient to establish improved net health outcomes or support routine use.

    Insufficient evidence: No controlled trials have compared electronic brachytherapy with alternative treatment options; therefore, conclusions cannot be drawn regarding comparative efficacy, safety, or improvement in net health outcome.

    The American Brachytherapy Society recommends use in the context of a clinical registry or trial, and NCCN states that insufficient long-term efficacy and safety data support routine use.

    Coding Information

    FDA Product Codemixed
    JADFDA product code for electronic brachytherapy systems used to treat nonmelanoma skin cancer
    CPTCPT
    77436Surface radiation therapy; superficial or orthovoltage, treatment planning and simulation-aided field setting.
    77437Surface radiation therapy; superficial, delivery, ≤150 kV, per fraction (e.g., electronic brachytherapy).
    77438Surface radiation therapy; orthovoltage, delivery, >150-500 kV, per fraction.
    77439Surface radiation therapy; superficial or orthovoltage, image guidance, ultrasound for placement of radiation therapy fields for treatment of cutaneous tumors, per course of treatment (List separately in addition to code for primary procedure).
    Investigational/deleted CPT codeCPTExperimental
    0394THigh dose rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, when performed (deleted 12/31/2025).
    ICD-10-CMICD-10
    C44.00-C44.99Codes for basal cell and squamous cell carcinomas of the skin; dependent on the anatomic location of the lesion.
    C44.211-C44.219Basal cell carcinoma of skin of ear and external auricular canal code range.
    C44.221-C44.229Squamous cell carcinoma of skin of ear and external auricular canal code range.
    C44.310-C44.319Basal cell carcinoma of skin of other and unspecified parts of face code range (includes nose).
    C44.320-C44.329Squamous cell carcinoma of skin of other and unspecified parts of face code range (includes nose).
    C44.41Basal cell carcinoma of skin of scalp and neck.
    C44.42Squamous cell carcinoma of skin of scalp and neck.
    ICD-10-PCSICD-10
    C44.42Squamous cell carcinoma of skin of scalp and neck.
    PCS Type of Servicemixed
    OncologyPCS Type of Service: Oncology.
    Service Place of Servicemixed
    OutpatientService Place of Service: Outpatient.

    Provider Actions

    Denial Risk

    Investigational treatment may be denied

    Electronic brachytherapy for the treatment of nonmelanoma skin cancer is considered investigational under this policy and may be denied.

    Clinical Background

    Nonmelanoma skin cancer (NMSC) primarily includes basal cell carcinoma and squamous cell carcinoma. Although these cancers are rarely fatal, they can affect quality of life, physical function, and appearance. Less common forms include T-cell lymphoma, Merkel cell tumor, basosquamous carcinoma, and Kaposi sarcoma.

    Surgery is generally the most effective treatment for NMSC. The approach depends on the lesion’s histologic type, size, and location, with Mohs micrographic surgery providing microscopic margin assessment and tissue-sparing precision for appropriate lesions. Cryosurgery, topical therapy, or radiotherapy may be considered when surgery is not feasible or preferred, is relatively contraindicated, or may produce an undesirable functional or cosmetic result. Radiotherapy has reported 5-year control rates of 80% to 92%, which are lower than those reported for surgical excision. Electronic brachytherapy is a localized radiotherapy technique that uses a miniaturized electronic X-ray source and a surface-fitted mold, typically delivered over multiple treatment sessions within a short period.

    Definitions

    Nonmelanoma Skin Cancer (NMSC)
    DefinitionNonmelanoma skin cancer (NMSC) refers to skin cancers other than melanoma.
    Principal cancer typesSquamous cell carcinoma (SCC) and basal cell carcinoma (BCC).
    Less common typesT-cell lymphoma and Merkel cell tumor; these may have treatment options that differ from SCC and BCC and may require individual consideration.
    Electronic Brachytherapy
    Treatment typeA localized form of radiotherapy delivered directly to the lesion.
    Radiation sourceA miniaturized electronic X-ray source is used instead of a radionuclide-based source.
    Policy Summary
    PayerBluecross Idaho
    PolicyElectronic Brachytherapy for Nonmelanoma Skin Cancer
    Policy CodePolicy N/A
    Change TypeLiterature and reference updateno material coverage change
    Effective DateJul 30, 2026
    Last ReviewJul 30, 2026
    Next Review DateN/A
    Key ActionTreat electronic brachytherapy for nonmelanoma skin cancer as investigational and apply the policy as a basis for denial.
    SourceLink
    On This Page
    Coverage CriteriaCoding InformationProvider ActionsClinical BackgroundDefinitions
    Tumor-surface mold
    A pliable silicone or polymethyl-methacrylate mold is fitted to the tumor surface, including nonflat areas such as the nose or ear.
    Nonmelanoma Skin Cancer (NMSC)
    NMSCNonmelanoma skin cancer refers to skin cancer other than melanoma.
    Squamous cell carcinomaSCC is one of the principal types of nonmelanoma skin cancer.
    Basal cell carcinomaBCC is one of the principal types of nonmelanoma skin cancer.
    Electronic Brachytherapy (EBT)
    DefinitionElectronic brachytherapy is locally delivered radiotherapy.
    Radiation sourceIt uses a miniaturized electronic X-ray source rather than a radionuclide-based source.
    Treatment scheduleMultiple treatment sessions are typically delivered within a short period, generally within one month.
    Mohs Micrographic Surgery (MMS)
    DefinitionMohs micrographic surgery is a surgical treatment in which cancerous tissue is removed in stages.
    Margin examinationThe margins are examined microscopically during the staged removal process.
    Comparator contextMohs surgery is one of the treatments currently used for NMSC and serves as a comparator for electronic brachytherapy.