Medical Policy Revision: Radioembolization for Primary and Metastatic Tumors of the Liver

Effective January 4, 2016, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain claims for radioembolization to treat primary and metastatic tumors of the liver.

According to the guidelines of our medical policy, Radioembolization for Primary and Metastatic Tumors of the Liver, radioembolization is considered:

• Medically necessary to treat primary hepatocellular carcinoma that is unresectable and limited to the liver.
• Medically necessary in primary hepatocellular carcinoma as a bridge to liver transplantation.
• Medically necessary to treat hepatic metastases from neuroendocrine tumors (carcinoid and noncarcinoid) with diffuse and symptomatic disease when systemic therapy has failed to control symptoms.
• Medically necessary to treat unresectable hepatic metastases from colorectal carcinoma, melanoma (ocular or cutaneous), or breast cancer that are both progressive and diffuse, in members with liver-dominant disease who are refractory to chemotherapy or are not candidates for chemotherapy or other systemic therapies.
• Medically necessary when utilized as a palliative procedure (e.g., reduction in tumor size to alleviate pain, etc.) or as an alternative procedure to manage disease progression when other therapies are not feasible or not effective.
• Investigational for all other hepatic metastases except as noted above.
• Medically necessary to treat primary intrahepatic cholangiocarcinoma in members with unresectable tumors.
• Investigational for all other indications not described above.

Based on the guidelines included in our revised medical policy, Radioembolization for Primary and Metastatic Tumors of the Liver, AND the submitted diagnosis or diagnoses code(s):

• Claims for services provided to members January 4, 2016 and after that include CPT® codes 37243, 75894 or HCPCS code S2095 may pend while information required to determine medical necessity is requested and reviewed.
• HCPCS code S2095 submitted on a claim for services provided on and after January 4, 2016 may be denied as an investigational service.

Review this revised policy in our online Medical Policy Manual.

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 January 4, 2016.

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