ModifiedKaiser PermanentePolicy N/A

Brachytherapy — Clinical Review Criteria

Clinical review criteria governing medical necessity and coverage guidance for brachytherapy procedures (including breast, prostate, cervical/endometrial, lung, coronary intravascular, and glioblastoma indications) for Kaiser Foundation Health Plan of Washington members and their providers.

Policy Summary

PayerKaiser Permanente

PolicyBrachytherapy — Clinical Review Criteria

Policy CodePolicy N/A

Change TypeMaterial and non‑material edits (added Medicare noteremoved deleted CPT codes)

Effective DateN/A

Next Review DateMar 3, 2026

Key ActionSubmit the last 6 months of clinical notes from the requesting provider and/or specialist to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Added language indicating that Medicare members will defer to KPWA criteria.

Removed several deleted CPT codes from the policy (77326, 77327, 77328, 77785, 77786, 77787, 0182T).

Removed additional CPT codes (55875, 55876, 55920, 57155, 57156).

Multiplesites addressed

≥50breast APBI age req

≤3 cmbreast tumor size limit

Manycodes covered when criteria met

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

03/03/2026policy maintenance

Coverage and Medical Necessity Criteria

Breast cancer — accelerated partial breast irradiation (APBI) as sole therapy

Covered when ALL of the following are met:

Age ≥ 50 (patients age 40-49 may be considered case-by-case)≥50 years

Invasive ductal cancer: Diagnosis of unifocal invasive ductal cancer with ALL of: tumor size ≤ 3 cm; negative surgical margins ≥ 2 mm; negative nodal statustumor ≤3 cm; margins ≥2 mm

DCIS alternative: Diagnosis of ductal carcinoma in situ (DCIS) with ALL of: detected on screening; low to intermediate nuclear grade; tumor size ≤ 2.5 cm; resected with margins negative at ≥ 3 mmDCIS ≤2.5 cm; margins ≥3 mm

Prostate — high-dose rate (HDR) brachytherapy

Considered medically necessary when ANY of the following are met:

HDR use cases: High-dose rate (HDR) prostate brachytherapy may be used when combined with external beam radiation as a boost OR when used for early-stage prostate disease as monotherapy

Standard brachytherapy covered without review

Covered without medical necessity review:

Covered standard brachytherapy: Coronary artery (intravascular) brachytherapy; Endobronchial brachytherapy for lung cancer; High-dose or low-dose brachytherapy for cervical and endometrial cancer; Prostate cancer brachytherapy; AccuBoost peripheral breast brachytherapy

Coverage determinations by indication

Coverage determinations based on MTAC evidence conclusions included in the document:

Coronary intravascular brachytherapy: Use meets Kaiser Permanente Medical Technology Assessment Criteria based on randomized trials showing reduced need for revascularization in in-stent restenosis

Trials include GAMMA-One, beta-WRIST, SCRIPPS

Breast APBI (balloon-based/AccuBoost) as adjunct/boost to WBRT: Insufficient evidence to determine non-inferiority or safety compared to whole breast irradiation; use as adjunct/boost does not meet MTAC criteria

Large RCTs ongoing (NSABP/RTOG and others)

Endobronchial brachytherapy for lung cancer: Evidence is insufficient/mixed; does not meet MTAC effectiveness criteria

Multiple RCTs with limitations reviewed

High-dose rate (HDR) brachytherapy for prostate cancer:

Prostate — HDR brachytherapy

HDR brachytherapy for prostate cancer:

Evidence conclusion: There is insufficient evidence to determine whether HDR brachytherapy given alone or in combination with EBRT is safe and effective for the treatment of prostate cancer.

Based on lack of randomized controlled trials and predominance of retrospective/case series data.

Cervical and Endometrial — HDR vs LDR

Cervical and endometrial cancer HDR vs LDR:

Cervical cancer evidence conclusion: With few exceptions, studies did not find statistically significant differences in survival or adverse effects between HDR and LDR brachytherapy for cervical cancer; however, trials had methodological limitations and were not designed as equivalence studies.

RCTs may have been underpowered and had allocation or validity limitations.

Endometrial cancer evidence conclusion: No studies specifically compare HDR and LDR brachytherapy for endometrial cancer.

No randomized controlled trials or empirical comparative studies identified.

Glioblastoma — radioactive seed brachytherapy

Recurrent high-grade glioblastoma:

Glioblastoma evidence conclusion: Published evidence consists primarily of case series with no reliable control groups; there is insufficient evidence to draw conclusions about the efficacy and safety of brachytherapy for recurrent high-grade glioblastoma.

Limitations include small sample sizes, selection bias, and lack of controlled comparisons.

Kaiser assessment — HDR brachytherapy

Kaiser Permanente Medical Technology Assessment conclusions:

Overall assessments: The use of HDR brachytherapy for prostate, cervical, and endometrial cancer does not meet the Kaiser Permanente Medical Technology Assessment Criteria (insufficient or inconclusive evidence).

Specifics and evidence limitations vary by tumor site as noted above.

Medically necessary procedural codes (when criteria met)

Procedures considered medically necessary:

Covered procedures: A list of CPT/HCPCS brachytherapy procedure codes are considered medically necessary when the applicable clinical criteria in this policy are met (see code groups). Providers should verify authorization requirements by plan.

See code group listing for specific CPT/HCPCS codes.

Contraindications and exclusions for accelerated partial breast irradiation (APBI) as the sole treatment modality are specified. Patients must be age ≥ 50 years to be eligible as a primary criterion (patients age 40–49 may be considered on a case-by-case basis). APBI as sole therapy is only appropriate for a unifocal invasive ductal carcinoma meeting ALL of: tumor size ≤ 3 cm, negative surgical margins ≥ 2 mm, and negative nodal status. As an alternative, selected ductal carcinoma in situ (DCIS) may be eligible only when detected on screening, of low-to-intermediate nuclear grade, tumor size ≤ 2.5 cm, and resected with margins negative at ≥ 3 mm. The procedure is contraindicated for patients who are age < 40, have lobular disease, have DCIS that does not meet the DCIS criteria above, have an extensive intraductal component (EIC), have relevant anatomic limitations preventing adequate target coverage, or have angiolymphatic space invasion.

The use of brachytherapy as an adjunct or boost to whole-breast radiation therapy is not supported by the Medical Technology Assessment Committee conclusions. MTAC found insufficient evidence to conclude that brachytherapy used as an adjunct/boost provides equivalent or superior outcomes compared with standard whole breast irradiation, and therefore this indication does not meet Kaiser Permanente MTAC criteria.

For endometrial cancer, the assessment identified no empirical studies that directly compare low-dose rate (LDR) and high-dose rate (HDR) brachytherapy. Because comparative evidence is absent, the use of HDR brachytherapy for endometrial cancer does not meet Kaiser Permanente Medical Technology Assessment Criteria.

High‑dose rate (HDR) brachytherapy for prostate and for cervical cancer was reviewed and the committee concluded there is insufficient evidence to determine whether HDR brachytherapy given alone or in combination with external beam radiation therapy is safe and effective. As a result, HDR brachytherapy for prostate and cervical cancer does not meet Kaiser Permanente MTAC criteria based on the reviewed evidence.

The use of brachytherapy as the sole alternative to whole-breast external beam radiation therapy (including balloon-based intracavity devices and AccuBoost approaches) was judged investigational/insufficient. MTAC reviews found that available studies were not designed as equivalence trials, had methodological limitations, and do not provide adequate high‑quality evidence to establish non-inferiority or safety compared with whole breast irradiation; therefore sole-use intracavity or peripheral brachytherapy for APBI does not meet MTAC criteria.

Endobronchial brachytherapy for lung cancer was evaluated in randomized trials with methodological limitations and overall was judged to have insufficient evidence of effectiveness; it does not meet MTAC criteria. Separately, HDR brachytherapy for prostate cancer similarly lacks adequate randomized controlled evidence and therefore does not meet MTAC criteria for effectiveness.

Summary conclusions across indications: HDR brachytherapy for prostate cancer lacks sufficient evidence to support safety and effectiveness; there are no empirical comparative studies comparing HDR and LDR brachytherapy for endometrial cancer; and brachytherapy for recurrent high‑grade glioblastoma is supported only by case series without control groups. These indications do not meet Kaiser Permanente MTAC criteria due to insufficient or inconclusive evidence of benefit.

Procedure Codes, Numeric Criteria, and Key Parameters

Considered Medically Necessary CPT/HCPCS Codes (when criteria met)mixedCovered

19296	Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; on date separate from partial mastectomy.
19297	Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; concurrent with partial mastectomy.
19298	Placement of radiotherapy after loading brachytherapy catheters (multiple tube and button type) into the breast for interstitial radioelement application following (at the time of or subsequent to) partial mastectomy, includes imaging guidance.
20555	Placement of needles or catheters into muscle and/or soft tissue for subsequent interstitial radioelement application.
31643	Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with placement of catheter(s) for intracavitary radioelement application.
41019	Placement of needles, catheters, or other device(s) into the head and/or neck region for subsequent interstitial radioelement application.
58346	Insertion of Heyman capsules for clinical brachytherapy.
61770	Stereotactic localization, including burr hole(s), with insertion of catheter(s) or probe(s) for placement of radiation source.
76965	Ultrasonic guidance for interstitial radioelement application.
77316	Brachytherapy isodose plan; simple (calculations from 1 to 4 sources, or remote afterloading brachytherapy, 1 channel).

1–10 of 25

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inv-24: Breast invasive tumor size — numeric parameter to display.

Breast invasive tumor size≤ 3 cm

ContextApplies to unifocal invasive ductal cancer eligible for APBI as sole therapy

Related requirementAlso requires negative surgical margins ≥ 2 mm and negative nodal status

inv-25: DCIS tumor size — numeric parameter to display.

DCIS tumor size≤ 2.5 cm

ContextDCIS must be detected on screening and be low-to-intermediate nuclear grade

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior authorization and documentation

Certain brachytherapy services require prior authorization and submission of supporting clinical documentation. Contact Member Services to confirm pre-authorization requirements and to verify whether the requested CPT/HCPCS code requires review.

Pre-authorization may be required for many listed brachytherapy CPT/HCPCS codes; use the Pre-authorization Code Check to verify by plan type.
When requesting services, include the last 6 months of clinical notes from the requesting provider and/or specialist to support medical necessity.

Note

Evidence-driven prior authorization

The use of accelerated partial breast irradiation (APBI) is being actively studied in large randomized controlled trials; coronary intravascular brachytherapy RCTs have shown reduced need for revascularization but long-term safety signals remain under investigation.

Ongoing large RCTs (NSABP/RTOG, RAPID, GEC-ESTRO) are assessing equivalence of APBI versus whole-breast RT.

Clinical Background and Evidence Summary

Background: Brachytherapy (internal radiation) delivers a high radiation dose localized to a target by placing radioactive sources either temporarily (high‑dose rate or low‑dose rate) or permanently (seed implants) within or next to the tumor. It is used as an alternative to surgery or as a boost to external beam radiation in breast, prostate, and gynecologic cancers and other anatomic sites. HDR techniques commonly employ an afterloader and allow modulation of dwell times and positions; permanent seed implants deliver LDR radiation with activity that decays over time.

Key Definitions and Device/Technique Descriptions

inv-46: Temporary vs Permanent brachytherapy — definition of temporary (LDR/HDR) and permanent (seed implantation).

Temporary brachytherapy (definition)Radioactive material placed inside/near tumor for a limited time; can be LDR or HDR

Permanent brachytherapy (definition)Seed implantation: radioactive seeds placed and left in place; activity decays over weeks–months

Clinical implicationTemporary techniques use afterloaders and removable catheters; permanent seeds remain and lose activity over time

inv-47: Balloon-based intracavity devices / Electronic brachytherapy / AccuBoost — device examples: MammoSite, Xoft Axxent, SenoRx Contura, AccuBoost.

Balloon-based intracavity devicesMammoSite; SenoRx Contura

Electronic brachytherapy device

Policy Maintenance and Revision Log

2026-05-27policy_revisionLatest

Added language indicating that Medicare members will defer to KPWA criteria.

2022-06-24code_update

Removed CPT codes 55875, 55876, 55920, 57155, and 57156 from the policy.

2020-06-02code_update

Policy Summary

PayerKaiser Permanente

PolicyBrachytherapy — Clinical Review Criteria

Policy CodePolicy N/A

Change TypeMaterial and non‑material edits (added Medicare noteremoved deleted CPT codes)

Effective DateN/A

Next Review DateMar 3, 2026

Key ActionSubmit the last 6 months of clinical notes from the requesting provider and/or specialist to support medical necessity.

SourceLink

On This Page

Insufficient evidence to determine safety and effectiveness as monotherapy or in combination with EBRT; does not meet MTAC criteria

Predominance of retrospective and case series data; no RCTs identified

Resected with margins negative at ≥ 3 mm

inv-26: Negative surgical margins (invasive) — numeric threshold.

Negative surgical margins (invasive)≥ 2 mm

ContextRequired for unifocal invasive ductal cancer to qualify for APBI as sole therapy

Associated tumor sizeTumor size must be ≤ 3 cm

inv-27: Negative surgical margins (DCIS) — numeric threshold.

Negative surgical margins (DCIS)≥ 3 mm

ContextRequired for DCIS cases being considered for APBI as sole therapy

Additional DCIS criteriaDetected on screening; low–intermediate nuclear grade; tumor ≤ 2.5 cm

inv-28: Age requirement for APBI as sole therapy — age threshold and case-by-case note.

Minimum age for APBI as sole therapy≥ 50 years

Case-by-case notePatients age 40–49 meeting requirements above may be considered on a case-by-case basis

ContraindicationAge < 40 is contraindicated

inv-29: HDR dose rate definition — numeric dose-rate definition.

HDR dose-rate definition50–500 cGy per minute

Typical sourceCommonly uses Iridium-192 afterloader for temporary HDR treatments

ApplicationHDR delivered via afterloader into catheters positioned in/near tumor with variable dwell times

Multiple RCTs (GAMMA-One, beta-WRIST, SCRIPPS, START) demonstrate reduced revascularization with intracoronary brachytherapy but with limited power for MACE outcomes.

Prior Authorization

Pre-authorization requirement for listed brachytherapy codes

Pre-authorization is required for the listed brachytherapy procedure codes when the applicable medical necessity criteria are not met or when plan rules specify prior authorization.

Affected CPT codes include, but are not limited to: 19296, 19297, 19298, 20555, 31643, 41019, 58346, 61770, 76965, 77316-77318, 77750, 77761-77763, 77768, 77770-77772, 77778, 77789, 77799, 0395T. HCPCS G0458 (LDR prostate composite rate) may also apply.
Deleted or out-of-effect codes may not be covered; verify authorization requirements via Pre-authorization Code Check.

Step Therapy

Step therapy

Step therapy is not applicable to brachytherapy services; there are no prescribed step sequences in this policy.

Note

Prostate care pathway

For prostate cancer, standard treatment pathways include EBRT (with or without hormone therapy) and standard surgical options. HDR brachytherapy is evaluated against these standard options and its use is subject to medical necessity criteria and evidence review.

EBRT (with or without androgen deprivation) and standard surgical procedures are considered standard management for intermediate and high-risk disease.
HDR brachytherapy has insufficient evidence to meet Kaiser Permanente MTAC criteria for prostate cancer when used alone or in some combinations; documentation should show consideration of standard options.

Documentation Required

Required clinical documentation

Submit the last 6 months of clinical notes from the requesting provider and/or specialist to support medical necessity for brachytherapy requests.

Include relevant consultation notes, diagnostic imaging, tumor staging, and prior treatment history in the documentation package.

Documentation Required

Intracoronary brachytherapy documentation

Intracoronary (endovascular) brachytherapy requires multidisciplinary documentation demonstrating involvement of the interventional cardiologist, radiation oncologist, medical physicist, and safety officer.

Document the indication (e.g., in-stent restenosis), prior interventions, angiographic findings, and the rationale for brachytherapy.
Include multidisciplinary treatment plan and post-procedure follow-up plan; note potential acute and long-term risks.

Documentation Required

Endobronchial brachytherapy procedural documentation

Endobronchial brachytherapy procedural documentation must include bronchoscopy details, fluoroscopic verification of catheter placement, dosing/fractionation, and detailed procedure notes due to procedure-specific risks.

Provide bronchoscopy report, catheter placement confirmation (fluoroscopy), source/dose/fractionation details, and concurrent EBRT use if applicable.
Be aware: endobronchial brachytherapy for lung cancer does not meet Kaiser Permanente MTAC effectiveness criteria; requests inconsistent with criteria may be denied.

Documentation Required

Prostate candidate screening documentation

Prostate seed implant candidate screening must be documented; include criteria used to identify eligible patients and evidence of consideration of alternative standard therapies.

Document risk stratification (stage, PSA, Gleason), imaging, and discussion of treatment options including LDR/HDR brachytherapy, EBRT, and surgery.
Screening criteria and follow-up plans should be included with the authorization request.

Denial Risk

Denial risk for nonconforming services

Requests that do not meet the applicable policy statements or MTAC determinations may be denied. Specific denial risks include use of brachytherapy as a boost/adjunct to whole-breast RT, endobronchial brachytherapy for lung cancer, and HDR brachytherapy for prostate cancer when evidence criteria are not met.

Brachytherapy as an adjunct/boost to whole-breast RT does not meet Kaiser Permanente MTAC criteria and is a denial risk.
Endobronchial brachytherapy for lung cancer does not meet MTAC criteria and may be denied.
High-dose rate brachytherapy for prostate cancer does not meet MTAC criteria (insufficient evidence) and may be denied when criteria are unmet.
Services not meeting applicable policy statements or using deleted/out-of-effect codes may be denied.

Xoft Axxent (50 kV electronic source)

AccuBoostAccuBoost peripheral breast brachytherapy (mammographic-guided applicators)

inv-48: High-dose rate (HDR) brachytherapy — temporary placement of high-intensity radioactive source (afterloader).

HDR brachytherapy (definition)Temporary placement of a high-intensity radioactive source (commonly Ir-192) delivered via an afterloader into catheters positioned in/near the tumor

Delivery characteristicAfterloader moves source to dwell positions and withdraws it after treatment

UseCan be delivered as monotherapy or combined with EBRT depending on indication

inv-49: Low-dose rate (LDR) brachytherapy — permanent implantation of low-activity radioactive seeds.

LDR brachytherapy (definition)Permanent implantation of low-activity radioactive seeds (seed implantation) that remain and decay over weeks–months

Dose distributionDose distribution depends primarily on seed placement

Clinical useCommonly used for prostate seed implants as monotherapy or combined with EBRT

inv-50: Intravascular coronary brachytherapy — localized intravascular delivery to inhibit neointimal hyperplasia.

Intravascular coronary brachytherapy (purpose)Localized intravascular delivery of beta or gamma radiation to inhibit neointimal hyperplasia and reduce in-stent restenosis

Follow-upEffect measured by angiographic follow-up at ~6 months to assess restenosis

Team requirementRequires multidisciplinary team including interventionist cardiologist and radiation oncologist

inv-51: HDR brachytherapy — shorthand label for High-dose rate (HDR).

HDR (shorthand)High-dose rate (HDR)

ContextUsed to denote temporary high-intensity brachytherapy techniques

Numeric range referenceSee numeric HDR definition (50–500 cGy/min) for dose-rate context

inv-52: HDR (numeric definition) — HDR generally defined as dose rate between 50–500 cGy/minute.

HDR numeric definitionDose rate generally defined as 50–500 cGy per minute

Source citationAccepted definition referenced to Tewari & DiSaia 2002; Hogberg et al., 1999

Applies toUse in policy to distinguish HDR from LDR temporary techniques

Removed deleted CPT codes 77326, 77327, 77328, 77785, 77786, 77787, and 0182T from the policy.

2020-07-07policy_effective_date

MPC approved updates to clinical indications for Non‑Medicare members, with 60‑day notice and effective date 2020-12-01.