CurrentEmblemHealthPolicy MG.MM.RA.12dC4

Selective Internal Radiation Therapy

Defines EmblemHealth's medical necessity criteria, limitations, and applicable procedure and diagnosis codes for outpatient selective internal radiation therapy (radioembolization) using Y-90 microspheres for unresectable primary or metastatic liver malignancies, and criteria for repeat treatments.

Policy Summary

PayerEmblemHealth

PolicySelective Internal Radiation Therapy

Policy CodePolicy MG.MM.RA.12dC4

Change TypeReviewed (no material change)

Effective Date

Next Review Date

Key ActionTreating physician or PCP must submit clinical evidence that the member meets the criteria (diagnosis, ECOG/KPS, life expectancy, prior imaging, prior response for repeats, LFTs, lung shunt/dose calculations); without documentation EmblemHealth will not review or certify the request.

POLICY UPDATE CHANGES

Document last reviewed on May 9, 2025; no specific clinical-policy changes documented in the header.

Revision history 2021-05-07 added covered indication for treatment of unresectable liver metastases from breast carcinoma, ocular melanoma, cutaneous melanoma, or intrahepatic cholangiocarcinoma.

Revision history 2019-03-08 added repeat radioembolization criteria.

>=3Minimum life expectancy for coverage (months)

ECOG 0-1Performance status required (initial)

ECOG <=2Performance status allowed for repeat

Coverage Summary

Overview: This policy (policy_number MG.MM.RA.12dC4) defines EmblemHealth coverage for Selective Internal Radiation Therapy (SIRT) / Yttrium-90 (Y-90) radioembolization for unresectable primary or metastatic liver malignancies. Status: CURRENT. Last review date: May 9, 2025. Coverage stance: covered_with_criteria. High-level allowed indications include treatment of unresectable and/or medically inoperable primary hepatocellular carcinoma and unresectable liver-only or liver-dominant metastases (examples: neuroendocrine tumors, colorectal metastases, and certain metastases such as breast carcinoma, ocular melanoma, cutaneous melanoma, or intrahepatic cholangiocarcinoma when other systemic or liver-directed options are not available). Only outpatient treatment is allowed unless inpatient necessity is documented, and only FDA‑approved microspheres (e.g., SIR‑Spheres, TheraSphere) will be considered medically necessary.

Quick-reference thresholds and limits

Minimum life expectancy>= 3 months

Initial performance statusECOG 0 or 1 OR KPS >= 70

Repeat performance statusECOG <= 2 OR KPS >= 70

Acceptable lung dose per treatment<= 25–30 Gy

Cumulative lung dose limit<= 50 Gy (all treatments)

Maximum number of radioembolizations2 (requests for a third will not be certified)

Medical-Necessity Criteria

Not Covered / Experimental

Exclusions and limits: Repeat whole‑liver irradiation is considered experimental, investigational, or unproven and will not be certified. Requests for a third radioembolization will not be certified (maximum allowed treatments implied as two). Treatment should be excluded when lung shunting results in an estimated lung radiation dose of greater than 25–30 Gy per treatment or a cumulative lung dose of greater than 50 Gy for all treatments; providers must submit lung shunting and dose calculations. Per provider_actions, the treating physician or PCP must supply clinical documentation (diagnosis, ECOG/KPS, life expectancy, prior imaging and response if repeat, LFTs, lung shunt/dose calculations); without this documentation EmblemHealth will not review or certify the request.

Coding

Applicable Procedure CodesCPT|HCPCSCovered

37243	Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction.
75894	Transcatheter therapy, embolization, any method, radiological supervision and interpretation.
77778	Interstitial radiation source application; complex.
79445	Radiopharmaceutical therapy, by intra-arterial particulate administration.
Q3001	Radioelements for brachytherapy, any type, each.
S2095	Transcatheter occlusion or embolization for tumor destruction, percutaneous, any method, using yttrium-90 microspheres.

Applicable Diagnosis Codes (ICD-10)ICD-10Covered

C22.0	Liver cell carcinoma.
C22.1	Intrahepatic bile duct carcinoma.
C22.2	Hepatoblastoma.
C22.3	Angiosarcoma of liver.
C22.4	Other sarcomas of liver.
C22.7	Other specified carcinomas of liver.
C22.8	Malignant neoplasm of liver, primary, unspecified as to type.
C22.9	Malignant neoplasm of liver, not specified as primary or secondary.
C78.7	Secondary malignant neoplasm of liver and intrahepatic bile duct.

Device / Microsphere RequirementneutralCovered

FDA-approved microspheres

Only FDA-approved microspheres will be considered medically necessary (examples: SIR-Spheres, TheraSphere).

Provider Actions

Prior Authorization

Preauthorization / Clinical documentation required

Treating physician or PCP must submit clinical evidence that member meets criteria (diagnosis, ECOG/KPS, life expectancy, prior imaging, prior response for repeats, LFTs, lung shunt/dose calculations); without documentation EmblemHealth will not review or certify the request.

Diagnosis
ECOG or KPS
Life expectancy
Prior imaging
Prior response for repeats
Liver function tests (LFTs)
Lung shunt and dose calculations

Documentation Required

Background & Evidence

Background: Selective Internal Radiation Therapy (SIRT), also called radioembolization or Y-90 hepatic brachytherapy, is an outpatient transcatheter technique that delivers radioactive Y-90 microspheres via the hepatic artery so implanted microspheres emit localized radiation to liver tumors. FDA‑approved devices cited in the policy include SIR‑Spheres and TheraSphere. EmblemHealth’s criteria are based on published literature, guideline sources (for example AASLD and NCCN), peer‑reviewed studies and consensus/practice parameters (e.g., ACR‑ABS‑ACNM‑ASTRO‑SIR‑SNMMI practice parameter), and expert clinical input.

Key evidence and guidelines

Definitions

Revision History

2025-05-09reviewedLatest

Document last reviewed on May 9, 2025; header indicates no specific clinical-policy changes documented at that review.

2021-05-07material_change

Revision added a covered indication for treatment of unresectable liver metastases from breast carcinoma, ocular melanoma, cutaneous melanoma, or intrahepatic cholangiocarcinoma.

2019-03-08material_change

Revision added criteria allowing repeat radioembolization (repeat radioembolization criteria included).