Coverage Policies

Use the index below to search for coverage information on specific medical conditions.

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If not specified in a QualChoice coverage policy (Benefit Interpretation), QualChoice follows care guidelines published by MCG Health.

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 10/26/2006 Title: Mammosite Procedure (Breast Brachytherapy)
Revision Date: 01/01/2017 Document: BI175:00
CPT Code(s): 19296-19298; 77326; 77370; 77750; 77761-77763; 77776-77778; 77785-77790; 77316-77318
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Breast brachytherapy is the direct treatment of breast cancer by placing radioactive substances into the exact portion of the breast from which an early cancer was removed. This is also known as a Mammosite procedure. After limited breast surgery for an early cancer, a reservoir (like a balloon) is placed in the portion of the breast from which the cancer was removed. Liquid preparations of radioactive substances are placed into the reservoir for defined amounts of time to irradiate the local tissues in an effort to reduce recurrence of the cancer.

2)    This treatment is covered by QualChoice.


Medical Statement

1)    There are three stages to the Mammosite procedure: insertion of the balloon, evaluation and set up for treatment, and treatment sessions. The treatment course is either one or two per day of therapy for a 5 day course.
QualChoice will recognize and compensate these sections of the process as follows:

a)    Insertion of the Balloon:

i)       One code in the range 19296-19298

b)    Initial radiation therapy evaluation and set up for treatment – one each of the following codes:

i)       77326; AND

ii)     77336; AND

iii)    77370

c)     Per treatment:

i)       Use modifier 76 if more than one treatment per day

ii)     77790 AND

iii)    One of 77761-77763

iv)   Plus appropriate HCPCS codes for the radioactive substance used.

Codes Used In This BI:

19296

Place po breast cath for rad

19297

Place breast cath for rad

19298

Place breast rad tube/caths

77326

Brachytx isodose calc simp

77370

Radiation physics consult

77750

Infuse radioactive materials

77761

Apply intrcav radiat simple

77762

Apply intrcav radiat interm

77763

Apply intrcav radiat compl

77776

Apply interstit radiat simpl

77777

Apply interstit radiat inter

77778

Apply interstit radiat compl

77785

Hdr brachytx 1 channel

77786

Hdr brachytx 2-12 channel

77787

Hdr brachytx over 12 chan

77789

Apply surface radiation

77790

77316     77317               

77318       

Radiation handling

Brachytherapy isodose plan; simple

intermediate

complex


Reference

Addendum:

Effective 01/01/2017: Removed deleted codes 77326 and code range 77781 – 77784 from Claim Statement section. These codes are no longer valid codes.


Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.