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    OpenPayerPolicy UpdatesRadiation OncologyExcellus Brachytherapy Coverage Update | OpenPayer
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    ModifiedExcellus Health Plan IncPolicy 6.01.16

    Brachytherapy or Radioactive Seed Implantation for Prostate Cancer

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    This policy governs coverage of permanent LDR and temporary HDR brachytherapy for localized prostate cancer, including monotherapy and brachytherapy boost used with EBRT.

    Policy Summary
    PayerExcellus Health Plan Inc
    PolicyBrachytherapy or Radioactive Seed Implantation for Prostate Cancer
    Policy CodePolicy 6.01.16
    Change TypeModified
    Effective DateDecember 22, 2025
    Last ReviewNov 20, 2025
    Next Review DateNovember 1, 2026
    Key ActionDocument the clinical and pathologic features needed to assign the patient to the applicable prostate cancer risk group.
    SourceLink
    POLICY UPDATE CHANGES

    New medically appropriate criteria were added for unfavorable intermediate-risk prostate cancer.

    CPT code 77014 was deleted from the policy because the code was termed on 2025-12-31.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    4Eligible monotherapy risk groups
    3Boost risk groups
    InvestigationalHigh-risk HDR monotherapy
    2Brachytherapy techniques
    Unfavorable intermediateNewly added risk group

    Medical Necessity and Clinical Criteria

    Medically appropriate indications

    Permanent LDR or temporary HDR brachytherapy for localized prostate cancer is medically appropriate when the treatment is used in one of the following configurations.

    Qualifying treatment configuration

    • Localized disease: The patient has localized prostate cancer.

    • ONE of the following

      • Monotherapy: Permanent LDR or temporary HDR brachytherapy is used alone as monotherapy for very low-risk, low-risk, favorable intermediate-risk, or unfavorable intermediate-risk prostate cancer.

        The applicable risk group is assigned using the policy’s prostate cancer risk-group definitions.

      • Brachytherapy boost: Permanent LDR or temporary HDR brachytherapy is used as a boost in conjunction with EBRT for unfavorable intermediate-risk, high-risk, or very high-risk prostate cancer.

        Document the concurrent or planned EBRT.

    Prostate cancer risk group definitions

    Assign the prostate cancer risk group using the clinical and pathologic features below.

    Risk group definitions

    • Low risk: All of the following are present: cT1-cT2a, Grade Group 1, and PSA less than 10 ng/mL; the patient does not qualify for very low risk.PSA <10 ng/mL
    • Favorable intermediate risk: All of the following are present: one intermediate-risk factor, Grade Group 1 or 2, and fewer than 50% of biopsy cores positive.<50% biopsy cores positive

      For example, fewer than 6 of 12 cores.

    • Unfavorable intermediate risk

      • Two or three intermediate-risk factors are present.

    Investigational HDR monotherapy

    The following use is investigational.

    Investigational use: Temporary HDR brachytherapy is used alone as monotherapy for high-risk prostate cancer.

    This use is considered investigational and is not included among the medically appropriate indications.

    Guideline-based clinical context

    Professional guidelines describe the following clinical-use patterns. These statements provide clinical context and are not stated as additional payer authorization requirements.

    Brachytherapy alone is an option for patients with very low-, low-, or favorable intermediate-risk prostate cancer, depending on life expectancy.Very low, low, or favorable intermediate risk

    NCCN V.2.2026.

    Combined treatment: For unfavorable intermediate-, high-, or very-high-risk disease, LDR or HDR brachytherapy may be added as a boost to EBRT, with ADT when clinically appropriate.Unfavorable intermediate, high, or very-high risk

    NCCN V.2.2026. GEC/ESTRO/ACROP recommends combining brachytherapy with EBRT for unfavorable intermediate- and high-risk localized disease (Grade A, Level 1a).

    Guideline-supported radiation treatment: For unfavorable intermediate- or high-risk prostate cancer in patients electing radiation therapy, clinicians may offer dose-escalated hypofractionated EBRT or combined EBRT plus LDR or HDR brachytherapy with a risk-appropriate course of ADT.

    Temporary HDR brachytherapy used alone as monotherapy for high-risk prostate cancer is considered investigational and is not included among the medically appropriate indications under this policy.

    Current evidence does not demonstrate that HDR brachytherapy used as the sole treatment for high-risk prostate cancer is superior to alternatives such as EBRT. Additional robust clinical trials are needed; available evidence suggests HDR brachytherapy may be more beneficial when combined with EBRT or hormone therapy.

    Consistent with this evidence, NCCN V.2.2026 describes patients with high-risk disease as generally poor candidates for brachytherapy alone. Brachytherapy may instead be added as a boost to EBRT plus ADT for unfavorable intermediate-, high-, or very-high-risk prostate cancer treated with curative intent.

    Procedure, Supply, and Diagnosis Codes

    CPT CodesCPT
    55875Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy.
    55876Placement of interstitial device(s) for radiation therapy guidance (e.g. fiducial markers, dosimeter), prostate (via needle, any approach), single or multiple.
    76873Ultrasound, transrectal; prostate volume study for brachytherapy treatment planning (separate procedure).
    76965Ultrasonic guidance for interstitial radioelement application.
    77021Magnetic resonance imaging guidance for needle placement (e.g., for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation.
    77316Brachytherapy isodose plan; simple (calculations made from 1 to 4 sources, or remote afterloading brachytherapy, 1 channel), includes basic dosimetry calculations.
    77317Brachytherapy isodose plan; intermediate (calculations made from 5 to 10 sources, or remote afterloading brachytherapy, 2-12 channels), includes basic dosimetry.
    77318Brachytherapy isodose plan; complex (calculations made from over 10 sources, or remote afterloading brachytherapy, over 12 channels), includes basic dosimetry.
    77387Guidance for localization of target volume for delivery of radiation treatment delivery, includes intrafraction tracking, when performed.
    77761Intracavitary radiation source application; simple.
    1–10 of 18
    1/2
    CPT Codes that may be considered Experimental/Investigational when used aloneCPTExperimental
    77770Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 1 channel.
    77772Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; over 12 channels.
    HCPCS CodesHCPCS
    C1716Brachytherapy source, nonstranded, gold-198, per source.
    C1719Brachytherapy source, nonstranded, non-high dose rate iridium-192, per source.
    C2637Brachytherapy source, nonstranded, ytterbium-169, per source.
    C2638Brachytherapy source, stranded, iodine-125, per source.
    C2639Brachytherapy source, nonstranded, iodine-125, per source.
    C2640Brachytherapy source, stranded, palladium-103, per source.
    C2641Brachytherapy source, nonstranded, palladium-103, per source.
    C2642Brachytherapy source, stranded, cesium-131, per source.
    C2643Brachytherapy source, nonstranded, cesium-131, per source.
    C2645Brachytherapy planar source, palladium-103, per square millimeter.
    1–10 of 14
    1/2
    CPT CodesCPT
    77387Guidance for localization of target volume for delivery of radiation treatment delivery, includes intrafraction tracking, when performed.
    77761Intracavitary radiation source application; simple.
    77762Intracavitary radiation source application; intermediate.
    77763Intracavitary radiation source application; complex.
    77778Interstitial radiation source application; complex, includes supervision, handling, loading of radiation source, when performed.
    77789Surface application of low dose rate radionuclide source.
    77790Supervision, handling, loading radiation source.
    77799Unlisted procedure, clinical brachytherapy.
    77770Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 1 channel.
    77772Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; over 12 channels.
    HCPCS CodesHCPCS
    C1716Brachytherapy source, nonstranded, gold-198, per source.
    C1719Brachytherapy source, nonstranded, non-high dose rate iridium-192, per source.
    C2637Brachytherapy source, nonstranded, ytterbium-169, per source.
    C2638Brachytherapy source, stranded, iodine-125, per source.
    C2639Brachytherapy source, nonstranded, iodine-125, per source.
    C2640Brachytherapy source, stranded, palladium-103, per source.
    C2641Brachytherapy source, nonstranded, palladium-103, per source.
    C2642Brachytherapy source, stranded, cesium-131, per source.
    C2643Brachytherapy source, nonstranded, cesium-131, per source.
    C2645Brachytherapy planar source, palladium-103, per square millimeter.
    1–10 of 14
    1/2
    ICD10 CodesICD-10
    C61Malignant neoplasm of prostate.
    D07.5Carcinoma in situ of prostate.

    Documentation and Coverage Considerations

    Documentation Required

    Document Prostate Cancer Risk Stratification

    Document the clinical and pathologic features used to assign the prostate cancer risk group before requesting brachytherapy coverage. The record should support the applicable risk-group definition and the planned brachytherapy configuration.

    • Very low risk: record the applicable NCCN clinical/pathologic criteria.
    • Low risk: cT1–cT2a, Grade Group 1, and PSA <10 ng/mL, without qualifying for very low risk.
    • Favorable intermediate risk: one intermediate-risk factor; Grade Group 1 or 2; and <50% of biopsy cores positive.
    • Unfavorable intermediate risk: two or three intermediate-risk factors, Grade Group 3, or >50% of biopsy cores positive. Intermediate-risk factors include cT2b–cT2c, PSA 10–20 ng/mL, and Grade Group 2 or 3.
    • High risk: at least one high-risk feature without meeting very high-risk criteria, including cT3a, Grade Group 4, or Grade Group 5.
    • Very high risk: at least two of cT3–cT4, Grade Group 4, or Grade Group 5.

    Clinical Background

    Brachytherapy is an internal radiation treatment in which sealed radioactive material is placed in or near the prostate tumor. Permanent LDR brachytherapy uses implanted radioactive seeds that release radiation gradually and remain in the prostate, while temporary HDR brachytherapy uses plastic catheters through which a high-energy radioactive source is inserted for calculated dwell times over multiple treatment fractions. Either approach may be delivered alone or used as a boost with external beam radiation therapy.

    Terms and Treatment Techniques

    Brachytherapy
    DefinitionInternal radiation treatment in which radioactive material is placed directly into a tumor or close to it.
    MaterialsThe radioactive material may be sealed in needles, seeds, wires, or catheters.
    GuidanceThe material is inserted and guided by radiological imaging, usually but not exclusively ultrasound.
    Permanent Low-Dose-Rate (LDR) Brachytherapy
    DefinitionPermanent prostate brachytherapy in which radioactive seeds are implanted interstitially through the transperineal route.
    Radiation deliveryThe seeds release radiation gradually at a low dose rate over approximately six to 12 months, after which they become inert.
    Policy Summary
    PayerExcellus Health Plan Inc
    PolicyBrachytherapy or Radioactive Seed Implantation for Prostate Cancer
    Policy CodePolicy 6.01.16
    Change TypeModified
    Effective DateDecember 22, 2025
    Last ReviewNov 20, 2025
    Next Review DateNovember 1, 2026
    Key ActionDocument the clinical and pathologic features needed to assign the patient to the applicable prostate cancer risk group.
    SourceLink
    On This Page
    Medical Necessity and Clinical CriteriaProcedure, Supply, and Diagnosis CodesDocumentation and Coverage ConsiderationsClinical BackgroundTerms and Treatment Techniques
  1. Grade Group 3 is present.
  2. More than 50% of biopsy cores are positive.>50% biopsy cores positive

    For example, more than 6 of 12 cores.

  3. High risk: At least one high-risk feature is present, including cT3a, Grade Group 4, or Grade Group 5, and the patient does not meet very-high-risk criteria.
  4. Very high risk: The patient has at least two of the following features: cT3-cT4 and Grade Group 4 or 5.At least 2 features

    For the brachytherapy-related recommendation, the policy also states prognosis greater than five years or symptomatic.

    5. AUA/ASTRO recommendation: Strong, Grade A/B.

    Documentation Required

    Document Brachytherapy Boost With EBRT

    For a brachytherapy boost, document that brachytherapy is being delivered in conjunction with external beam radiation therapy (EBRT), and identify the qualifying risk group.

    • Brachytherapy boost with EBRT is an applicable configuration for unfavorable intermediate-risk, high-risk, or very high-risk disease.
    • Specify whether EBRT is concurrent or planned as part of the treatment course.
    Documentation Required

    Document Very High-Risk Disease Circumstances

    For very high-risk disease, document the circumstances supporting the treatment plan, including whether the patient has a prognosis greater than five years or is symptomatic.

    • Very high-risk disease requires at least two of: cT3–cT4, Grade Group 4 or 5.
    • Record prognosis >5 years or symptomatic status, as applicable.
    • The source treatment pathway identifies radiation therapy plus androgen-deprivation therapy (ADT) plus abiraterone for patients with prognosis greater than five years or symptomatic disease.

    Unsupported block type: denial_risk

    Denial Risk

    Risk Group and Treatment Configuration Must Qualify

    Confirm that both the risk group and treatment configuration meet the policy criteria before requesting or billing for brachytherapy. Permanent LDR or temporary HDR brachytherapy is appropriate as monotherapy only for the listed risk groups, or as a boost when combined with EBRT for the listed higher-risk groups.

    • Monotherapy: permitted for very low-risk, low-risk, favorable intermediate-risk, or unfavorable intermediate-risk localized prostate cancer.
    • Brachytherapy boost with EBRT: permitted for unfavorable intermediate-risk, high-risk, or very high-risk disease.
    • Document the treatment configuration explicitly; high-risk disease does not qualify for HDR monotherapy.
    • Ensure the submitted risk group is supported by the clinical and pathologic documentation described in the risk-stratification requirements.
    ImplantationThe seeds do not have to be removed and can remain in the prostate for the rest of the patient's life.
    Temporary High-Dose-Rate (HDR) Brachytherapy
    DefinitionTemporary prostate brachytherapy in which plastic catheters are placed in the prostate and a high-energy radioactive source is temporarily inserted.
    Treatment deliveryRadiation is delivered through the catheters in multiple treatments, or fractions, over several sessions per day or over several days.
    Source timingThe source is inserted for calculated dwell times at various positions within the prostate.
    Image-Guided Radiation Therapy (IGRT)
    DefinitionImage-guided radiation therapy uses dedicated treatment-room devices for fraction-by-fraction imaging and guidance.
    LocalizationIGRT localizes the target and normal structures at the time of treatment.
    FunctionThe imaging supports precise and accurate radiation placement; CT, MRI, ultrasound, and x-ray may be used.
    HDR Brachytherapy
    TechniqueTiny plastic catheters are placed into the prostate for delivery of HDR brachytherapy.
    RadioisotopeA high-energy radioisotope such as iridium-192 is delivered through the catheters.
    Dwell positionsThe source is temporarily inserted for calculated durations at multiple dwell positions, generally for eight to 12 minutes.
    LDR Brachytherapy
    TechniqueLDR brachytherapy uses permanently implanted radioactive seeds placed through the transperineal approach.
    Imaging guidanceImplantation may be guided by transrectal ultrasound, fluoroscopy, and/or computed tomography.
    Clinical descriptionThe transperineal approach provides disease control in low-stage and low- to moderate-grade tumors.
    IGRT
    Imaging during treatmentIGRT uses dedicated imaging devices during treatment to localize the target and normal structures.
    Precision supportImaging supports precise radiation placement and highly conformal dose distributions.
    Treatment adjustmentScans are compared with simulation reference images and allow adjustment based on tumor position, size, and shape.
    Androgen Deprivation Therapy (ADT)
    DefinitionADT is androgen deprivation therapy, also referred to as hormone therapy.
    Neoadjuvant roleHormone therapy may be used before permanent seed implantation, HDR brachytherapy, or external beam radiation therapy.
    Treatment purposeNeoadjuvant therapy may selectively reduce prostate size and induce tumor regression.
    Afterloading
    DefinitionAfterloading is the process of temporarily inserting the radioactive source into the prostate for a calculated duration and then removing it.
    Dwell positionsThe source is positioned at various dwell positions within the prostate.
    Typical durationThe source is usually present for approximately eight to 12 minutes during each treatment delivery.