Medical Policy Revision: Radiation Treatment of Bone Metastases

Effective April 6, 2017, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain claims for radiation treatment of bone metastases.

Our revised medical policy, Radiation Treatment of Bone Metastases, identifies when the use of conventional external beam radiation therapy using simple 2-Dimensional (2D) planning techniques, the use of conformal radiation therapy techniques including 3-Dimensional conformal radiation therapy (3D CRT) and intensity-modulated radiation therapy (IMRT), the use of Stereotactic Body Radiosurgery (SBRT), or the use of Radium-223 (Xofigo^®) would be considered medically necessary or investigational.

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

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

• Claims for services provided on and after April 6, 2017 that include CPT^® codes 77373 or 77435, or HCPCS code A9606 will pend while information required to determine medical appropriateness is requested and reviewed.

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 April 6, 2017.

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