Palmetto GBA Releases SRS and SBRT Final Policies

Palmetto GBA Releases SRS and SBRT Final Policies

On January 30, 2009 Palmetto Government Benefits Administrators released the final Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) policies. These policies will be effective on March 16, 2009

in California, Nevada, and Hawaii for services performed in outpatient facilities and hospitals. Both policies are now available on the draft policy section of the Palmetto Website at: www.palmettogba.com

Stereotactic Body Radiation Therapy Local Coverage Determination

In addition to the indications proposed in the draft policy, G0339, G0340, 77373 and 77435 will be covered for the following, effective March 16, 2009:

157.0 Malignant neoplasm of head of pancreas

157.1 Malignant neoplasm of body of pancreas

157.2 Malignant neoplasm of tail of pancreas

157.3 Malignant neoplasm of pancreatic duct

157.4 Malignant neoplasm of islets of langerhans

157.8 Malignant neoplasm of other specified sites of pancreas

157.9 Malignant neoplasm of pancreas part unspecified

185 Malignant neoplasm of prostate

197.8*Secondary malignant neoplasm of other digestive organs and spleen

133.4 Carcinoma in situ of prostate

236.5 Neoplasm of uncertain behavior of prostate

* Limited to secondary malignant neoplasm of the pancreas

For prostate cancer, Palmetto states:

The clinical experience with SBRT for carcinoma of the prostate is of short term duration relative to the natural history of prostate cancer. Published peer reviewed studies of the success and complication rates are still small and of short or medium term duration. Prominent specialty societies and academicians suggest SBRT is still investigational, while others who currently use the equipment feel SBRT has some selected advantages. We will cover SBRT for prostate cancer only when:

  1. Other forms of first line therapy are not available or feasible since other forms have known long term success and complication rates; and
  2. All of the criteria listed above are documented in the medical record; or
  3. The patient is enrolled in an approved clinical study listed in ClinicalTrials.Gov

For sites interested in enrolling patients in prostate clinical studies, please contact Joanne Davis at jdavis@accuray.com.

 

Stereotactic Radiosurgery Local Coverage Determination

Since the SRS policy was first implemented on September 2, 2008 Palmetto has made two significant revisions. The first round of revisions, effective January 1, 2009, was made to the policy currently in effect. These revisions mainly reflect annual CPT coding updates related to the surgeons’ code 61793. The second round of revisions was made to the draft policy that will be effective on March 16, 2009. All changes will reflected in the final policy effective on March 16, 2009.

In addition to the indications proposed in the draft policy G0339, G0340, 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77371, 77372, 77373, 77432, and 77435 will be covered for the following, effective March 16, 2009:

  • 170.2 Malignant neoplasm of vertebral column excluding sacrum and coccyx
  • 192.2 Malignant neoplasm of temporal lobe
  • 192.3 Malignant neoplasm of spinal meninges
  • 213.2 Benign neoplasm of vertebral column excluding sacrum and coccyx
  • 255.3 Benign neoplasm of spinal cord
  • 255.4 Benign neoplasm of spinal meninges
  • 747.82Spinal vessel anomaly

Palmetto also made revisions to the language governing surgeon participation in order to hold neurological surgeons to the same participating standards as the radiation oncologists. Specifically Palmetto removed the statement “during the complete course” and replaced with the statement “in the coded course of the procedure” in the following sentence: The comprehensive CPT code 61796, 61797, 61798, 61799, 61800, 63620 and 63621 may be billed by the neurosurgeon, as one member of the team, when and only when this physician is (a) present, (b) medically necessary and (c) fully participating, in the coded course of the procedure. The medical record must clearly indicate the critical nature of the anatomy or other circumstances necessitating the services encompassed by this code.

The statement “It is not appropriate to bill for this code for any other circumstance” was removed from the same paragraph.

The CyberKnife® Coalition is pleased that Palmetto has made these very positive changes to both the SRS and SBRT policies. We will continue to work with Palmetto to correct the robotic radiosurgery coding restrictions in order to improve patient access to the CyberKnife System technology.

For questions about these policies or to discuss how we may work with you to improve these policies, please email info@ckcoalition.org .