CurrentHealth-New-EnglandPolicy UM975POL

Superficial Radiation Therapy for the Treatment of Nonmelanoma Skin Cancers - Medical Policy

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Coverage of superficial radiation therapy for cutaneous basal cell carcinoma, squamous cell carcinoma, and squamous cell carcinoma in situ across Commercial, Medicare Advantage, and Medicaid lines of business.

Policy Summary

PayerHealth-New-England

PolicySuperficial Radiation Therapy for the Treatment of Nonmelanoma Skin Cancers

Policy CodePolicy UM975POL

Change TypeAdministrative updateno material clinical or coverage change

Effective DateAugust 1, 2026

Next Review DateN/A

Key ActionSubmit clinical evidence demonstrating that the patient meets the applicable treatment criteria for prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Covered malignancy categories for SRT when criteria are met

4 cmMaximum lesion size for covered SRT indications

6 mmDepth threshold above which SRT is not medically necessary

2CPT codes listed for superficial radiation therapy

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CurrentHealth-New-EnglandPolicy UM975POL

Superficial Radiation Therapy for the Treatment of Nonmelanoma Skin Cancers - Medical Policy

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Policy Summary

PayerHealth-New-England

PolicySuperficial Radiation Therapy for the Treatment of Nonmelanoma Skin Cancers

Policy CodePolicy UM975POL

Change TypeAdministrative updateno material clinical or coverage change

Effective DateAugust 1, 2026

Next Review DateN/A

Key ActionSubmit clinical evidence demonstrating that the patient meets the applicable treatment criteria for prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Covered malignancy categories for SRT when criteria are met

4 cmMaximum lesion size for covered SRT indications

6 mmDepth threshold above which SRT is not medically necessary

2CPT codes listed for superficial radiation therapy

3Health New England lines of business identified

Prior authorizationReview pathway requiring clinical evidence

Medical Necessity and Coverage Criteria

Medically Necessary SRT

SRT is medically necessary when ALL of the following are met:

ALL of the following

ONE of
- Low-risk cutaneous basal cell carcinoma (BCC) or high-risk cutaneous BCC as classified by NCCN®, ASTRO, and AAD guidelines.
- Low-risk cutaneous squamous cell carcinoma (SCC) or high-risk cutaneous SCC as classified by NCCN®, ASTRO, and AAD guidelines.
- Cutaneous SCC in situ as classified by NCCN®, ASTRO, and AAD guidelines.
The patient is a documented nonsurgical candidate.

Nonsurgical candidacy is supported when surgery would cause loss of function, significant morbidity, or poor cosmesis in an anatomically sensitive area (such as the ears, nose, lips, or eyelids), or when shared decision-making is documented and the patient refuses surgery as a treatment option.

HRUS-Guided SRT and EBT — Not Medically Necessary

The following uses of treatment are not medically necessary:

ONE or more

Use of high-resolution ultrasound (HRUS) to guide SRT delivery.
Use of HRUS to assess lesion reduction during the superficial radiation treatment protocol.
Electronic surface brachytherapy (EBT) for treatment of nonmelanoma skin cancers (NMSCs).
Long-term efficacy and safety data are insufficient, consistent with the consensus of the literature and recommendations of the AAD, ASTRO, and ABS.

Non-Medically Necessary SRT Indications

SRT is not medically necessary when ANY of the following indications or tumor characteristics apply:

ANY of the following

SRT is selected as a first-line treatment option in a surgical candidate.
SRT is used to treat advanced BCC or SCC.
The patient has an NMSC and a contraindication to radiation therapy (RT).
The cutaneous tumor arises in a previously irradiated field or treatment would be expected to involve overlapping fields.
Cutaneous SCC is greater than 4 cm in size.> 4 cm

Very high-risk SCC is not amenable to SRT. Tumor depth must be measured before any preoperative curettage or other treatment to the lesion. Deep invasion for SCC is defined as invasion beyond the subcutaneous fat or a depth greater than 6 mm, measured from the granular layer of adjacent normal epidermis to the base of the tumor.

Very high-risk SCC should be treated with surgical excision with peripheral and deep en face margin assessment (PDEMA) or Mohs micrographic surgery (MMS), with or without adjuvant RT based on consultation with a radiation oncologist, or with external beam radiation therapy (EBRT), consistent with NCCN® guidelines.

SRT is not medically necessary for cutaneous tumors with perineural or perivascular invasion when SRT would be the sole treatment option.

Use of HRUS to guide SRT delivery or to assess lesion reduction during the superficial radiation treatment protocol is not medically necessary and is not supported by the literature.

EBT for treatment of NMSCs is not medically necessary. Long-term efficacy and safety data are insufficient to support electronic surface brachytherapy, consistent with the consensus of the literature and recommendations of the AAD, ASTRO, and ABS.

SRT is not medically necessary when used as a first-line treatment option in a surgical candidate, for advanced BCC or SCC, or for patients with NMSCs who have contraindications to RT. It is also not medically necessary for cutaneous tumors arising in previously irradiated fields or when overlapping treatment fields would be expected.

SRT is not medically necessary for tumors exceeding the specified size or depth thresholds, including cutaneous SCC greater than 4 cm, cutaneous BCC greater than 4 cm, or cutaneous NMSC deeper than 6 mm. It is also not medically necessary for cutaneous NMSCs with aggressive morphology, tumors with perineural or perivascular invasion when SRT is the sole treatment option, or very high-risk SCC.

Coding and Treatment Parameters

Surface radiation therapy CPT codesCPT

77436	Surface radiation therapy; superficial or orthovoltage, treatment planning and simulation-aided field setting.
77437	Surface radiation therapy; superficial delivery, ≤150 kV, per fraction (e.g., electronic brachytherapy).

Maximum cutaneous SCC size

Maximum size≤4 cm

Applies toCutaneous squamous cell carcinoma (SCC)

Not medically necessary above thresholdSRT is not medically necessary for cutaneous SCC larger than 4 cm.

Maximum cutaneous BCC size

Maximum size≤4 cm

Applies toCutaneous basal cell carcinoma (BCC)

Not medically necessary above thresholdSRT is not medically necessary for cutaneous BCC larger than 4 cm.

Authorization and Documentation Requirements

Note

Medicare-Specific Criteria

For Medicare members, apply the applicable InterQual criteria for superficial radiation therapy (SRT) for the treatment of nonmelanoma skin cancers (NMSC), including the criteria associated with LCD L35936.

Medicare: Procedures, Superficial Radiation Therapy (SRT) for the Treatment of Nonmelanoma Skin Cancers (NMSC) NGS.
Superficial Radiation Therapy for the Treatment of Nonmelanoma Skin Cancers.

Prior Authorization

Clinical Evidence Required

Prior authorization requests must include clinical evidence and supporting information sufficient for Health New England to determine whether the requested SRT meets the policy criteria.

Clinical Background

Nonmelanoma skin cancers (NMSCs), primarily basal cell carcinoma and squamous cell carcinoma, are common cutaneous malignancies. Treatment selection is based on factors including recurrence risk, expected cure, morbidity, preservation of function, and cosmetic outcome. Most NMSCs are treated surgically through traditional excision or Mohs micrographic surgery. SRT uses low-energy radiation directed at superficial lesions and may be considered for selected patients who are not surgical candidates; risk category and tumor characteristics are important when determining whether SRT is appropriate.

Key Definitions

Superficial radiation therapy (SRT)

ModalitySuperficial radiation therapy uses low-energy x-rays or photons.

Energy rangeGenerally 50 to 150 kV per treatment.

Treatment useTreats superficial cutaneous malignancies while sparing deeper structures.

Electronic brachytherapy (EBT)

Treatment typeA form of superficial radiation treatment.

Applicator-based sourceA high-dose x-ray source is placed directly into a skin applicator near the surface.

Dose delivery

Policy Summary

PayerHealth-New-England

PolicySuperficial Radiation Therapy for the Treatment of Nonmelanoma Skin Cancers

Policy CodePolicy UM975POL

Change TypeAdministrative updateno material clinical or coverage change

Effective DateAugust 1, 2026

Next Review DateN/A

Key ActionSubmit clinical evidence demonstrating that the patient meets the applicable treatment criteria for prior authorization.

SourceLink

On This Page

Cutaneous BCC is greater than 4 cm in size.> 4 cm

The cutaneous NMSC has a depth greater than 6 mm.> 6 mm

The cutaneous NMSC has aggressive morphology.

The cutaneous tumor has perineural or perivascular invasion and SRT is the sole treatment option.

The tumor is very high-risk SCC.

Maximum NMSC depth

Maximum depth≤6 mm

Applies toCutaneous nonmelanoma skin cancers (NMSCs)

Not medically necessary above thresholdSRT is not medically necessary for cutaneous NMSCs deeper than 6 mm.

SRT treatment energy

General treatment range50–150 kV per treatment

CPT 77437 limit≤150 kV per fraction

Treatment modalityLow-energy kilovoltage x-rays or photons used for superficial treatment

Documentation Required

Tumor Diagnosis and Risk Category

Document the tumor diagnosis and applicable risk category under NCCN®, ASTRO, and AAD guidelines. SRT may be medically necessary for a low-risk or high-risk cutaneous basal cell carcinoma (BCC), a low-risk or high-risk cutaneous squamous cell carcinoma (SCC), or cutaneous SCC in situ, when the patient is a nonsurgical candidate.

Cutaneous BCC: identify whether the lesion is low-risk or high-risk.
Cutaneous SCC: identify whether the lesion is low-risk or high-risk.
Cutaneous SCC in situ: document the diagnosis and guideline-based classification.

Documentation Required

Nonsurgical Candidacy

Document why the patient is a nonsurgical candidate. Examples include anticipated loss of function, significant morbidity, poor cosmesis in an anatomically sensitive area, or documented shared decision-making in which the patient refuses surgery as a treatment option.

Relevant sensitive areas include the ears, nose, lips, and eyelids.
Include the clinical rationale and, when applicable, documentation of shared decision-making.

Prior Authorization

Submit Evidence of Criteria Fulfillment

The treating physician or primary care provider must submit clinical evidence demonstrating that the patient meets the treatment criteria. Without the required documentation and supporting information, Health New England cannot properly review the prior authorization request.

Submit supporting clinical evidence with the prior authorization request.
Documentation must address the diagnosis, risk category, and applicable medical-necessity criteria.

Denial Risk

HRUS-Guided SRT and EBT

Do not request coverage for HRUS-guided SRT or for using HRUS to assess lesion reduction during the superficial radiation treatment protocol. Electronic brachytherapy (EBT) for NMSC is also not medically necessary.

HRUS guidance for SRT delivery is not medically necessary.
HRUS assessment of lesion reduction during treatment is not medically necessary.
EBT for NMSC is not medically necessary because long-term efficacy and safety data are insufficient.

Denial Risk

Inappropriate Clinical Setting

Flag requests in which SRT is proposed as first-line treatment for a surgical candidate, for advanced BCC or SCC, for a patient with contraindications to radiation therapy, or for tumors arising in previously irradiated fields or involving expected overlapping fields.

First-line SRT in a surgical candidate is not medically necessary.
SRT for advanced BCC or SCC is not medically necessary.
SRT is not medically necessary when the patient has contraindications to radiation therapy.
Previously irradiated or overlapping treatment fields are not medically necessary indications.

Denial Risk

High-Risk Tumor Characteristics

Flag tumor characteristics that make SRT not medically necessary, including size, depth, aggressive morphology, invasion features, and very high-risk SCC.

Cutaneous SCC greater than 4 cm.
Cutaneous BCC greater than 4 cm.
Cutaneous NMSC with depth greater than 6 mm.
Cutaneous NMSC with aggressive morphology.
Perineural or perivascular invasion when SRT is the sole treatment option.
Very high-risk SCC.

Denial Risk

Insufficient Clinical Documentation

If the treating physician or primary care provider does not submit the required clinical evidence and supporting information, Health New England will be unable to properly review the prior authorization request or determine whether the service meets the medical-necessity criteria.

Obtain and submit the documentation needed to evaluate the request.
Missing documentation may limit or prevent medical-necessity review.

Provides a relatively homogeneous dose pattern to a specified depth.

Radioactive isotopeDoes not require a radioactive source.

Nonmelanoma skin cancer (NMSC)

Full termNonmelanoma skin cancer (NMSC)

Cancer typeKeratinocyte carcinoma.

Included malignanciesBasal cell carcinoma (BCC) and squamous cell carcinoma (SCC), including SCC in situ.

Deep invasion

DefinitionFor SCC, deep invasion means invasion beyond the subcutaneous fat or greater than 6 mm from the granular layer of adjacent normal epidermis to the tumor base.

Measurement referenceDepth is measured from the granular layer of adjacent normal epidermis to the base of the tumor.

Staging standardThe definition is consistent with the American Joint Committee on Cancer Staging Manual, 8th Edition.

Nonsurgical candidate

Functional impactSurgery would cause loss of function.

MorbiditySurgery would result in significant morbidity.

CosmesisSurgery would cause poor cosmesis in an anatomically sensitive area, such as the ears, nose, lips, or eyelids.

Refusal after shared decision-makingThe patient refuses surgery after documented shared decision-making.