CurrentKaiser PermanentePolicy N/A

Clinical Review Criteria Superficial Radiation Therapy (Electronic Brachytherapy for Non-Melanoma Skin Cancer)

Clinical review criteria for use of superficial electronic brachytherapy (EBT/EBX/eBT) for treatment of non-melanoma skin cancer (NMSC) for Kaiser Foundation Health Plan of Washington members, including Medicare-specific notes and applicable billing codes. Defines coverage stance, evidence conclusions, documentation to submit, and lists applicable procedure and diagnosis codes.

Policy Summary

PayerKaiser Permanente

PolicyClinical Review Criteria Superficial Radiation Therapy (Electronic Brachytherapy for Non-Melanoma Skin Cancer)

Policy CodePolicy N/A

Change TypeAdded MTAC review; codes updated; MPC affirmed non-coverage

Effective DateAug 2, 2024

Next Review DateApr 1, 2025

Key ActionWhen requesting EBT for NMSC, submit the last 6 months of clinical notes from the requesting provider and/or specialist to support medical necessity.

POLICY UPDATE CHANGES

Added the July 2024 MTAC Review.

MPC approved MTAC's recommendation of insufficient evidence and maintain the policy of non-coverage.

Updated applicable codes by adding: 77280, 77285, 77300, 77336, 77370, 77401 and G6001 with applicable skin cancer diagnosis.

Removed deactivated CPT code 0182T and CPT code 77401 (historical note).

Added MTAC review (04/05/2016) and later guideline references (NCCN, Hayes).

1Primary CPT code listed as EBT

9+Related CPT/HCPCS codes listed

40+ICD-10 diagnosis codes listed

Coverage Determination

Services are considered NOT MEDICALLY NECESSARY / experimental, investigational, or unproven when used for electronic brachytherapy for NMSC except where Medicare-specific guidance applies

ALL of the following

Evidence conclusion: insufficient published evidence to determine net health outcomes of electronic brachytherapy (EBT) for NMSC
Comparative efficacy: Insufficient evidence to determine comparative efficacy vs Mohs micrographic surgery or other standard therapies; available evidence limited to case series and small observational studies
MTAC/Assessment: MTAC and KPWA Medical Technology Assessment: use of electronic brachytherapy for NMSC does not meet Kaiser Permanente Medical Technology Assessment Criteria
Medicare note: For Medicare members: no applicable NCD; Noridian LCD for non-intracoronary brachytherapy (L34065) retired; decisions must meet medical necessity as outlined in LCD but retired LCD cannot be cited on appeal

Documentation Required for Requests

If requesting this service, submit ALL of the following:

Documentation required: Last 6 months of clinical notes from requesting provider and/or specialist

Procedure and Diagnosis Codes

Primary procedure considered (not medically necessary)CPTNot Covered

0394T

High dose rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, when performed.

Related radiotherapy procedure codes (applicable codes list)CPT

77280	Therapeutic radiology simulation-aided field setting; simple.
77285	Therapeutic radiology simulation-aided field setting; intermediate.
77300	Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor; tissue inhomogeneity factors...
77336	Continuing medical physics consultation, including assessment of treatment parameters... reported per week of therapy.
77370	Special medical radiation physics consultation.
77401	Radiation treatment delivery, superficial and/or orthovoltage, per day.
77412	Radiation treatment delivery, >=1 MeV; complex.
G6001	Ultrasonic guidance for placement of radiation therapy fields.

Diagnosis codes referenced (skin cancer / carcinoma in situ)ICD-10

C44.01	Basal cell carcinoma of skin of lip
C44.02	Squamous cell carcinoma of skin of lip
C44.1121	Basal cell carcinoma of skin of right upper eyelid, including canthus
C44.1122
C44.1191	Basal cell carcinoma of skin of left upper eyelid, including canthus
C44.1192	Basal cell carcinoma of skin of left lower eyelid, including canthus
C44.1221	Squamous cell carcinoma of skin of right upper eyelid, including canthus
C44.1222	Squamous cell carcinoma of skin of right lower eyelid, including canthus
C44.1291	Squamous cell carcinoma of skin of left upper eyelid, including canthus
C44.1292

1–10 of 49

1/5

Prior Authorization and Documentation

Prior Authorization

Prior authorization / medical necessity review required

Electronic brachytherapy (EBT) for non-melanoma skin cancer requires a medical necessity review. Under this Clinical Review Criteria EBT is considered experimental/investigational and not medically necessary. Verify any required authorization for the member's plan using the Pre-authorization Code Check.

Affected procedure codes: 0394T, 77280, 77285, 77300, 77336, 77370, 77401, 77412, G6001
Verify authorization requirements for specific plan types with the Pre-authorization Code Check

Documentation Required

Submit clinical notes

Submit documentation to support medical necessity for requests for EBT for NMSC. Specifically, provide the last 6 months of clinical notes from the requesting provider and/or specialist.

Last 6 months of clinical notes from the requesting provider and/or specialist

Documentation Required

Medicare member determination

For Medicare members, the Noridian Local Coverage Determination L34065 (Brachytherapy: Non-intracoronary) has been retired and therefore cannot be cited on appeal. Decisions for Medicare members must meet medical necessity; KPWA will apply its Clinical Review Criteria and medical judgment for determinations and reviews.

Retired Noridian LCD L34065 cannot be specifically referenced on appeal
Services for Medicare members still must meet medical necessity and will be reviewed using KPWA Clinical Review Criteria or medical judgment

Background, Evidence, and Definitions

Electronic Brachytherapy (EBT) is a low-energy, isotope-free, high-dose-rate brachytherapy technique that delivers HDR brachytherapy using a miniaturized electronic x-ray source and conical applicators for skin surface application. Systems use low-energy bremsstrahlung x-rays (typically 20–70 keV) with applicator sizes selected to cover the clinical target volume and common fractionation regimens reported include 40 Gy in 8 fractions delivered twice weekly over about 4 weeks.

Surgery (including excision and Mohs micrographic surgery) remains the standard treatment for non-melanoma skin cancer (NMSC); radiation therapies, including EBT, are typically considered second-line for patients who are not suitable surgical candidates or when surgery would cause unacceptable functional or cosmetic outcomes.

The Medical Technology Assessment Committee (MTAC) and subsequent evidence reviews have concluded there is insufficient published evidence to determine the safety and efficacy of EBT for NMSC and that EBT does not meet Kaiser Permanente Medical Technology Assessment criteria. MTAC noted the evidence base is limited and that no randomized controlled trials demonstrate comparative long-term efficacy or safety versus standard treatments.

MTAC Evidence Conclusion: Insufficient published evidence to determine safety and efficacy of EBT for NMSC; the use of electronic brachytherapy for non-melanoma skin cancer does not meet Kaiser Permanente Medical Technology Assessment Criteria.

Key studies: Available evidence is limited to case series and small observational studies — notably the Bhatnagar series with initial 2010 reports and 1-year results in 2013 — and additional small retrospective series. MTAC and later reviews found no randomized controlled trials comparing EBT to alternative therapies (including Mohs micrographic surgery), and recommended that randomized controlled trials with adequate follow-up are needed to determine comparative long-term safety and efficacy.

Electronic Brachytherapy (EBT/eBT/EBX): High-dose-rate brachytherapy delivered by a low-energy miniaturized electronic x-ray source rather than a radionuclide-based source, used with conical applicators for skin surface application; cited advantages include isotope‑free delivery, reduced shielding needs, and no radioactive waste.

MTAC: Medical Technology Assessment Committee — the committee that reviewed the evidence for EBT in NMSC and concluded there is insufficient published evidence to support safety and efficacy compared with standard treatments.

name	number	type	effective
Noridian retired LCD Brachytherapy: Non-intracoronary	L34065	LCD	retired (date not specified)

Policy Revision History

08/06/2024MPC actionLatest

MPC approved MTAC's recommendation of insufficient evidence and to maintain the policy of non-coverage.

08/02/2024document update

Added the July 2024 MTAC Review.

04/26/2024code update

Updated applicable codes by adding: 77280, 77285, 77300, 77336, 77370, 77401 and G6001 with applicable skin cancer diagnosis.

08/04/2020historical update

Removed deactivated CPT code 0182T and CPT code 77401 (historical note).

04/05/2016historical update

Added MTAC review (historical update reflecting 2016 MTAC review).

04/25/2017historical update

Added NCCN guideline references (historical update).

04/17/2018historical update

Added Hayes guideline references (historical update).