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Medical Policy Revision: Radiation Treatment of Bone Metastases

Effective March 15, 2016, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain claims for radiation treatment of bone metastases.

According to the guidelines of our revised medical policy, Radiation Treatment of Bone Metastases:

  • Conventional external beam radiation therapy using simple 2-Dimensional (2D) planning techniques is considered medically necessary as palliative treatment for bone metastases for: pain related to the bone metastasis; patients at high risk of an impending fracture; post-operative pain from repair of a pathological fracture; and symptomatic spinal cord compression. Simple planning techniques are appropriate for the majority of individuals requiring palliative treatment for bone metastases.
     
  • Use of conformal radiation therapy techniques including 3D conformal radiation therapy (3D CRT) and intensity-modulated radiation therapy (IMRT) are generally considered not medically necessary for the treatment of bone metastases.

    3D CRT may be considered when there is a significant complex extraosseous component to the target volume.

    IMRT may be considered where overlap with previous radiotherapy fields is likely to cause complications.
     
  • Stereotactic Body Radiosurgery (SBRT) is not a standard method of care and is generally considered not medically necessary.

    SBRT may be considered in cases that require treatment to a portion of the spine that has been previously irradiated and in cases of radio-resistant tumors (sarcoma, melanoma and renal cell carcinoma) that have metastasized to the spine.

We encourage you to review this revised policy in our online Medical Policy Manual.

Based on the guidelines of our revised medical policy, Radiation Treatment of Bone Metastases AND the submitted diagnosis code(s):

  • Claims for services provided on and after March 15, 2016 that include CPT® codes 77301, 77385, 77386, 77387, 77338 or HCPCS codes G6015, G6016 may pend while information to determine medical appropriateness is requested and reviewed.
     
  • CPT codes 77301, 77385, 77386, 77387, 77338 or HCPCS codes G6015, G6016 submitted on claims for services provided on and after March 15, 2016 may be denied as investigational or not medically necessary services.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims for dates of service on and after March 15, 2016.

CPT® is a registered mark of the American Medical Association.

Published on: December 16, 2015, 11:00 a.m. ET
Last updated on: November 24, 2020, 23:49 p.m. ET