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    v1.0.28
    OpenPayerPolicy UpdatesRadiation OncologyIndependent Health Barrigel Coverage Prior Auth | …
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    CurrentIndependent HealthPolicy M20240924031

    Transperineal Placement of Biodegradable Material for Prostate Cancer (Barrigel)

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    Defines Independent Health's medical necessity criteria and coverage stance for transperineal placement of the biodegradable rectal spacer Barrigel in members undergoing external radiotherapy for localized prostate cancer; applies to commercial, Medicare Advantage, and specified state plans.

    Policy Summary
    PayerIndependent Health
    PolicyTransperineal Placement of Biodegradable Material for Prostate Cancer (Barrigel)
    Policy CodePolicy M20240924031
    Change TypeMinor — no material changes
    Effective DateNov 1, 2024
    Next Review Date
    Key ActionObtain preauthorization and document imaging confirming organ-confined prostate cancer without rectal invasion or posterior extension.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    FDA-clearedRegulatory
    Covered w/ criteriaCoverage

    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.

    PreauthAuthorization
    Rectal invasion/T3Exclusion
    MediSource, MAPD, CommercialLOBs

    Coverage Criteria

    Medical necessity criteria

    Covered when ALL of the following are met

    ALL of the following

    • Anatomic placement: The Barrigel will be implanted between the prostate and rectum
    • Treatment intent: The member is undergoing external radiotherapy with organ-confined prostate cancer in order to displace the rectum from high radiation dose regions
    • Imaging criteria: Imaging indicates the cancer has not invaded into the rectum or extended beyond the posterior region of the prostate

      Patients with obvious rectal invasion or visible T3 and posterior extension should not undergo perirectal spacer implantation (not covered).

    Patients who have obvious rectal invasion by prostate cancer or a visible T3 posterior extension should not undergo perirectal spacer (Barrigel) implantation. This anatomic finding indicates tumor extension into or through the posterior prostate margin and/or rectal wall, and perirectal spacer placement is contraindicated because it would not achieve the intended separation and may interfere with appropriate oncologic management.

    Perirectal spacer implantation in the presence of rectal invasion or posterior extension (visible T3) is considered not covered / not medically necessary under this policy.

    Coding

    Covered CPT Codes (per document references)CPTCovered
    CPT 55874Transperineal placement of biodegradable material (e.g., perirectal spacer) for prostate radiation therapy

    Provider Actions & Requirements

    Prior Authorization

    Prior Authorization Required

    Preauthorization is required for transperineal placement of biodegradable material (Barrigel). Providers must obtain prior authorization before scheduling or performing this service. Lack of required preauthorization may result in denial of payment.

    • CPT 55874
    Note

    LOB-specific Requirement

    For MediSource, MediSource Connect, Child Health Plus and Essential Plan members, coverage follows the Commercial criteria when using CPT 55874. For these lines of business, transperineal placement of biodegradable material is not covered unless the Commercial criteria are met.

    • Applies to: MediSource, MediSource Connect, Child Health Plus, Essential Plan
    • Affected code: CPT 55874

    Background

    Rectal toxicity from prostate radiotherapy results from the close proximity of the prostate and rectum and may present as diarrhea, fecal incontinence, proctitis, or ulceration. Biodegradable perirectal spacers such as Barrigel are injected between the prostate and rectum to temporarily increase separation, reduce rectal dose during external radiotherapy, and thereby decrease the risk of radiation-induced rectal toxicity. Barrigel is a biodegradable rectal spacer intended to position the anterior rectal wall away from the prostate for the duration of radiotherapy.

    Definitions

    Barrigel — definition and composition
    Product nameBarrigel injectable gel
    CompositionNonanimal stabilized hyaluronic acid (NASHA) at 20 mg/mL in phosphate buffered saline; described elsewhere in the policy as biodegradable hyaluronic acid and polyethylene glycol formulations
    Formulation / deliveryInjectable gel delivered via syringe under ultrasound guidance (transrectal ultrasound) for transperineal placement between the prostate and rectum
    Intended useTemporarily position the anterior rectal wall away from the prostate during radiotherapy for localized prostate cancer to reduce rectal radiation dose
    Duration / biodegradationMaintains space for the radiotherapy course (~3 months) and subsequently degrades by hydrolysis with renal excretion by about 6 months
    Policy Summary
    PayerIndependent Health
    PolicyTransperineal Placement of Biodegradable Material for Prostate Cancer (Barrigel)
    Policy CodePolicy M20240924031
    Change TypeMinor — no material changes
    Effective DateNov 1, 2024
    Next Review Date
    Key ActionObtain preauthorization and document imaging confirming organ-confined prostate cancer without rectal invasion or posterior extension.
    SourceLink
    On This Page
    Coverage CriteriaCodingProvider Actions & RequirementsBackgroundDefinitions
    Documentation Required

    Required Clinical Documentation

    Documentation must demonstrate that the member has organ-confined prostate cancer without rectal invasion or posterior extension, and that imaging confirms placement between the prostate and rectum. Clinical records should include imaging reports (e.g., MRI or transrectal ultrasound), indication for external beam radiotherapy, and operative or procedure notes documenting Barrigel insertion and anatomic placement.

    • Imaging confirming no rectal invasion and no posterior extension
    • Evidence the Barrigel will be implanted between prostate and rectum
    • Plan for external radiotherapy for localized, organ-confined prostate cancer
    • Procedure note documenting Barrigel insertion and technique
    Denial Risk

    Clinical Exclusion — Denial Risk

    Patients with obvious rectal invasion or visible T3 posterior extension are excluded from coverage. Placement in these patients is not covered and claims for such procedures will be denied.

    • Not covered: Obvious rectal invasion
    • Not covered: Visible T3 posterior extension
    Prior Authorization

    Preauthorization Requirement (Repeat Emphasis)

    Preauthorization is required for this service. Failure to obtain preauthorization may result in denial of the claim.

    • Obtain prior authorization before service date
    • Denial may occur if preauthorization is not obtained