    
Final Comments Avail
Board Administrator
Username: Admin
Post Number: 67
Registered: 10-2002
| | Posted on Wednesday, July 09, 2008 - 05:27 pm: | 
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Comments
LCD Title
Stereotactic Body Radiation Therapy
Contractor's Determination Number
RAD-039
Comments:
Addition of Spine
1. Under "Indications" – Point A – we recommend adding "spine" to the lists of sites that may be treated. The spine is not included in the cranial SRS / SRT policy and therefore should be addressed in the SBRT policy.
2. We recommend adding 198.5 (Secondary malignancy Bone and Bone Marrow) to the list of ICD-9 codes.
3. Our interpretation of the document is that treatment of bone lesions is not allowed unless other radiation modalities have been utilized first. Our view is that spine SBRT should not be limited to re-irradiation in cases that meet the other criteria listed. There are patients with melanoma or renal cell bone mets, for example, who may live for a very long time, in whom conventional radiation is not effective. In these patients, requiring that conventional radiation be used first could be harmful and result in higher complication rates.
There is conflicting information; adrenal is listed as allowed and as excluded. Please see the following two excerpts below.
• Indications for SBRT for lung, liver, kidney, adrenal gland, or pancreas neoplasms: SBRT is covered for primary and metastatic tumors of the lung, liver, kidney, adrenal gland, or pancreas when and only when each of the following criteria are met, and each specifically documented in the medical record:
• Other Neoplasms: Lesions of bone, adrenal, prostate, breast, uterus, ovary and other internal organs not listed above are not covered for primary definitive SBRT as literature does not support an outcome advantage over other conventional radiation modalities, but may be appropriate for SBRT in the setting of recurrence after conventional radiation modalities.
4. Indications for SBRT for lung, SPINE, liver, kidney, adrenal gland, or pancreas neoplasms:
SBRT is covered for primary and metastatic tumors of the lung, SPINE, liver, kidney, adrenal gland, or pancreas when and only when each of the following criteria are met, and each specifically documented in the medical record:
Response:
At this point we have decided not to add spine as a site for treatment with SBRT. As the literature accumulates on this we can put it up for reconsideration. Our statement follows:
C. Other Neoplasms:
Lesions of bone, breast, uterus, ovary and other internal organs not listed above are not covered for primary definitive SBRT as literature does not support an outcome advantage over other conventional radiation modalities, but may be appropriate for SBRT in the setting of recurrence after conventional radiation modalities.
Comments:
Addition of Prostate Cancer
1. Thank you for the opportunity to comment on the Stereotactic Body Radiotherapy (SBRT) draft proposals. The indications for prostate SBRT are expanding from just using it for recurrent prostate cancer cases (as indicated in the draft policy) to using it as a treatment option for newly diagnosed prostate cancer. There is increasing data that larger doses per fraction are of benefit in prostate cancer and clinical studies also support this concept (see attached data). The entire radiation treatment is given in 5 sittings as opposed to 40 or more sessions with IMRT. When giving large doses per fraction it is extremely important to account for prostate location immediately prior to treatment and prostate movement during treatment by using real time image guidance throughout treatment. In our institution we use the Cyberknife system to deliver SBRT which can track target location in real time. Patients with Prostate Cancer are being treated with SBRT on national protocols at our institution and others. These treatments are very well tolerated, more convenient to the patient and less expensive than a course of IMRT treatment. However the ICD 9 185 for prostate cancer is not included in the list of ICD 9 codes listed in the document for SBRT as covered indications and I would recommend that this ICD 9 code be also included especially for patients being treated on protocol and for patients with recurrent disease as stated in the draft policy. I enclose some articles on prostate cancer SBRT from recent national meetings and peer reviewed literature.
2. I request you also consider SBRT as combination therapy for patients with high risk prostate cancer.
3. Current treatment options for prostate cancer typically include surgical resection, radiation therapy, hormonal therapy or watchful waiting. With radiation therapy there can be negative effects to the surrounding normal tissue. Brachytherapy with seed implants is an option as well as HDR Brachytherapy as treatments for prostate cancer. There is no clear superior therapy in terms of disease free survival. We recognize that stereotactic radiosurgery is not the primary treatment option for all prostate tumors.
We request you give consideration to coverage of SBRT for prostate cancer.
4. The pinpoint accuracy of treatment delivery, the advanced verification system and reduction in required patient treatments resulting in diminished side affects are all indicators that patient medical necessity would be better served by treatment of these prostate tumors with SBRT.
5. The application of SBRT is not new or unproven treatment. Instead it is the application of a long-accepted treatment. Using approved technologies. Approval of hypofractionation SBRT is of particular importance to citizens of a state where there is a large isolated rural population. The prospect of going trough conventionally fractionated, once daily radiation therapy, over a period of 7-8 weeks is simply impossible for some patients. Many of these patients are also not candidates for surgery or interstitial brachytherapy for other medical reasons. The availability of a non-invasive, external radiation therapy option that can be delivered in just 4-5 treatments, offers patients a curative treatment that will otherwise be denied to them.
Response:
We have added conditional coverage of prostate cancer to the policy based on the scientific literature provided.
B. SBRT for Prostate Neoplasms
SBRT of the prostate is covered as monotherapy for patients with low risk and low/intermediate risk prostate cancer when:
1. The patient's general medical condition (notably, the performance status) justifies aggressive treatment to a primary cancer. Typically, such a patient would have also been a potential candidate for alternate forms of intense local therapy applied for the same purpose.
2. Other forms of radiotherapy, including but not limited to external beam and IMRT or seed implantation, cannot be as safely or effectively utilized, and
3. The tumor burden can be completely targeted with acceptable risk to critical normal structures
Comments:
Code for surgeon work
1. I have a question that I hope you can help me understand. My question pertains to the LCD for Stereotactic Body Radiation Therapy. Is it appropriate for a surgeon to bill the CPT code 61793 for body radiosurgery (ie, lung, liver, pancreas, etc.)? The Body Radiation Therapy LCD appears to reference only 77373 and 77435 and indicates all other radiation oncology (professional and technical) are coded separately and should be addressed in separate LCD's. No where in the Body Radiation Therapy LCD do I find referenced a surgeon CPT code 61793. I find the CPT code 61793 referenced only for a "neurosurgeon" in the LCD for Stereotactic Radiosurgery (brain and spine diagnoses). In summary, can a surgeon (that is not a neurosurgeon) bill 61793 for body radiation therapy?
2. I have been told that there will be a new code for the surgeons no sooner than 2009. Hospitals and neurosurgery have their own codes to use so how come not urology?
Response:
To respond in a temporary way we have provided some NOC codes to use until true codes are developed.
Unlisted codes for surgeon work
32999 lungs and pleura Use these to report the surgeons role in stereotactic radiosurgery (one or more sessions) Place the term "stereotactic radiosurgery" in Item 19 on the claim form.
These can only be billed once per course of treatment.
Comment
"All SBRT is performed with at least one form of image guidance to confirm proper patient positioning and tumor localization. To minimize intra-treatment tumor motion associated with respiration or other motion, some form of motion control or "gating" may be used."
I suggest that instead of using the word "may", we change that to "should."
"All SBRT is performed with at least one form of image guidance to confirm proper patient positioning and tumor localization. To minimize intra-treatment tumor motion associated with respiration or other motion, some form of motion control or "gating" should be used."
Response:
We changed the sentence to read.
All SBRT is performed with at least one form of image guidance to confirm proper patient positioning and tumor localization. To minimize intra-treatment tumor motion associated with respiration or other motion, some form of motion control or "gating" should be used.
Comment:
Other Neoplasms:
Lesions of bone, adrenal, prostate, breast, uterus, ovary and other internal organs not listed above are not covered for primary definitive SBRT as literature does not support an outcome advantage over other conventional radiation modalities, but may be appropriate for SBRT in the setting of recurrence after conventional radiation modalities.
Malignant lesions of the Head & Neck or paranasal sinuses may be appropriate for SBRT following other conventional radiation modalities to complete initial definitive therapy.
Response:
Adrenal was removed from the policy.
Comment
ADD CPT 196.0 – 196.9 – Secondary or Unspecified Malignant Neoplasm of Lymph Nodes
Response:
We received no information to support the addition of these ICD-9 codes.
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