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    v1.0.28
    OpenPayerPolicy UpdatesRadiation OncologyHealth Choice AZ Brachytherapy Coverage | OpenPaye…
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    CurrentHealth Choice ArizonaPolicy O698.10

    Endobronchial Brachytherapy

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    This policy governs coverage determinations for endobronchial brachytherapy, including when the service is medically necessary and when it is considered experimental or investigational. Coverage remains subject to the member's benefit eligibility, and providers must submit complete medical rationale for exceptions.

    Policy Summary
    PayerHealth Choice Arizona
    PolicyEndobronchial Brachytherapy
    Policy CodePolicy O698.10
    Change TypeNo material change
    Effective DateSep 19, 2022
    Last ReviewAug 16, 2022
    Next Review Date3rd Qtr 2023
    Key ActionDocument that the patient meets at least one medical-necessity indication and provide complete medical rationale for any exception request.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    2Medical-necessity indications
    3Experimental or investigational triggers

    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.

    3
    Examples of experimental or investigational uses
    8Listed CPT codes
    6Protected characteristics
    2Interpreter service numbers

    Medical Necessity and Investigational Use

    Medically necessary indications

    Covered as medically necessary when ANY of the following are met:

    Qualifying medical-necessity indication

    • Primary endobronchial tumor without surgical or external-beam options: The individual has a primary endobronchial tumor and is not otherwise a candidate for surgical resection or external-beam radiotherapy due to comorbidities or tumor location.
    • Palliative treatment: The service is used as palliative therapy for airway obstruction or severe hemoptysis in an individual with a primary, metastatic, or recurrent endobronchial tumor.

    Experimental or investigational uses

    Considered experimental or investigational when the service is used for an indication not listed above or the medical-necessity criteria are not met, and ANY one or more of the following applies:

    Experimental or investigational determination

    • Regulatory approval lacking: There is a lack of final approval from the appropriate governmental regulatory bodies, such as the Food and Drug Administration.
    • Insufficient scientific evidence: Scientific evidence is insufficient to permit conclusions concerning the effect on health outcomes.
    • Insufficient evidence outside investigational setting: Evidence is insufficient to support improvement outside the investigational setting.

    Use of endobronchial brachytherapy as a radiation boost to curative external-beam radiotherapy is considered experimental or investigational.

    Use of endobronchial brachytherapy to treat asymptomatic recurrences of non-small-cell lung cancer is considered experimental or investigational.

    Use of endobronchial brachytherapy to treat hyperplastic granulation tissue is considered experimental or investigational.

    CPT Coding

    CPT CodesCPT
    3164331643
    7731677316
    7731777317
    7731877318
    7776177761
    7776277762
    7776377763
    7779077790

    Documentation and Coverage Risk

    Documentation Required

    Document Qualifying Indication and Medical Rationale

    Document the medical rationale establishing that endobronchial brachytherapy meets a listed medically necessary indication. Include the applicable clinical circumstances and why alternative treatment is not appropriate when relevant.

    • Primary endobronchial tumor when the individual is not otherwise a candidate for surgical resection or external-beam radiotherapy because of comorbidities or tumor location.
    • Palliative treatment of airway obstruction or severe hemoptysis in an individual with a primary, metastatic, or recurrent endobronchial tumor.
    Denial Risk

    Indication or Evidence Requirements Not Met

    Endobronchial brachytherapy for indications other than those listed, or when the medical-necessity criteria are not met, is considered experimental or investigational when any one or more evidence or regulatory requirements apply.

    Clinical Background

    Endobronchial brachytherapy delivers radiotherapy directly to endobronchial lesions. Treatment may be delivered intraluminally or interstitially using permanently implanted radioactive seeds or a temporary afterloading implant. The targeted approach is intended to limit radiation exposure to nearby radiosensitive structures, including normal lung, heart, and spinal cord.

    Policy Definitions

    Endobronchial brachytherapy
    DefinitionDelivery of radiotherapy directly to endobronchial lesions, either intraluminally or interstitially, using permanently implanted radioactive seeds or a temporary afterloading implant.
    Treatment approachTargeted radiation delivery to endobronchial lesions.
    PurposeThe technique permits targeted radiation while minimizing exposure to surrounding radiosensitive structures, such as normal lung, heart, and spinal cord.
    Experimental or investigational
    Policy meaningFor purposes of this policy, the terms experimental and investigational are considered to be interchangeable.
    ApplicationThe interchangeable terms are used in determining whether a service, procedure, medical device, or drug meets the policy criteria for coverage.
    Policy Summary
    PayerHealth Choice Arizona
    PolicyEndobronchial Brachytherapy
    Policy CodePolicy O698.10
    Change TypeNo material change
    Effective DateSep 19, 2022
    Last ReviewAug 16, 2022
    Next Review Date3rd Qtr 2023
    Key ActionDocument that the patient meets at least one medical-necessity indication and provide complete medical rationale for any exception request.
    SourceLink
    On This Page
    Medical Necessity and Investigational UseCPT CodingDocumentation and Coverage RiskClinical BackgroundPolicy Definitions
    • Lack of final approval from the appropriate governmental regulatory bodies, such as the Food and Drug Administration.
    • Insufficient scientific evidence to permit conclusions concerning the effect on health outcomes.
    • Insufficient evidence to support improvement outside the investigational setting.
    • Examples include use as a radiation boost to curative external-beam radiotherapy, treatment of asymptomatic recurrences of non-small-cell lung cancer, and treatment of hyperplastic granulation tissue.
    Regulatory contextState or federal mandates may affect whether an FDA-approved drug, device, or biological product is considered experimental or investigational; such products may instead be assessed only on the basis of medical necessity.