LCD/NCD Portal

L28756

 

ACCELERATED PARTIAL BREAST IRRADIATION (APBI)

 

02/02/2009

 

Indications and Limitations of Coverage and/or Medical Necessity

• APBI after breast-conserving surgery is considered medically necessary for patients with early stage breast cancer when all of the following criteria is met:

o Diagnosis: Invasive carcinoma or ductal carcinoma in situ of the breast.

o Size: < 3cm.

o Margin status: Negative - at least 2 mm in all directions

o Nodal status: Negative axillary lymph node dissection or sentinel lymph node evaluation.

Coding Information

 

Bill Type Codes

• Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service.

• Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type.

• Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

 

 

13x Hospital Outpatient

85x Critical Access Hospital

 

Revenue Codes

• Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service.

• In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination.

• Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

 

 

0333 Radiology - Therapeutic and/or Chemotherapy Administration - Radiation Therapy

 

 

CPT/HCPCS Codes

 

 

19296 PLACEMENT OF RADIOTHERAPY AFTERLOADING EXPANDABLE CATHETER (SINGLE OR MULTICHANNEL) INTO THE BREAST FOR INTERSTITIAL RADIOELEMENT APPLICATION FOLLOWING PARTIAL MASTECTOMY, INCLUDES IMAGING GUIDANCE; ON DATE SEPARATE FROM PARTIAL MASTECTOMY

19297 PLACEMENT OF RADIOTHERAPY AFTERLOADING EXPANDABLE CATHETER (SINGLE OR MULTICHANNEL) INTO THE BREAST FOR INTERSTITIAL RADIOELEMENT APPLICATION FOLLOWING PARTIAL MASTECTOMY, INCLUDES IMAGING GUIDANCE; CONCURRENT WITH PARTIAL MASTECTOMY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

 

 

ICD-9 Codes that Support Medical Necessity

 

 

174.0 MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST

174.1 MALIGNANT NEOPLASM OF CENTRAL PORTION OF FEMALE BREAST

174.2 MALIGNANT NEOPLASM OF UPPER-INNER QUADRANT OF FEMALE BREAST

174.3 MALIGNANT NEOPLASM OF LOWER-INNER QUADRANT OF FEMALE BREAST

174.4 MALIGNANT NEOPLASM OF UPPER-OUTER QUADRANT OF FEMALE BREAST

174.5 MALIGNANT NEOPLASM OF LOWER-OUTER QUADRANT OF FEMALE BREAST

174.6 MALIGNANT NEOPLASM OF AXILLARY TAIL OF FEMALE BREAST

174.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF FEMALE BREAST

174.9 MALIGNANT NEOPLASM OF BREAST (FEMALE) UNSPECIFIED SITE

233.0 CARCINOMA IN SITU OF BREAST

 

 

Documentation Requirements

• The following information must be clearly documented in the patient’s medical record; per the selection criteria listed in the Indications and Limitations of Coverage section:

o Diagnosis: Invasive carcinoma or ductal carcinoma in situ of the breast.

o Size: < 3cm.

o Margin status: Negative - at least 2 mm in all directions.

o Nodal status: Negative axillary lymph node dissection or sentinel lymph node evaluation.

Treatment Logic

• Prior to breast conservation procedures, virtually all women with operable breast cancer underwent a mastectomy.

• Long-term studies now demonstrate equivalent local control and overall survival with lumpectomy followed by radiation compared to mastectomy.

• Accelerated partial breast irradiation (APBI) uses radiation that targets only a segment surrounding the tumor rather than the entire breast.

• The duration of treatment is 4 to 5 days and is delivered in fewer fractions at larger doses per fraction.

 

Sources of Information and Basis for Decision

 

ACR/ASTRO Whitepaper, December, 2003.

 

Arthur D, Vicini F, Kuske RR, et al. Accelerated partial breast irradiation: An updated report from the American Brachytherapy Society. Brachytherapy 2002; 1(4):184-190.

 

BlueCross BlueShield Association Technology Evaluation Center (TEC) Assessment. Brachytherapy for accelerated partial breast irradiation after breast-conserving surgery for early stage breast cancer. 2002 Dec;17(8).

 

Coleman, C. N., P. E. Wallner, et al. (2003). "Inflammatory breast issue." J Natl Cancer Inst 95(16): 1182-3.

 

Consensus statement for Accelerated Partial Breast Irradiation form the American Society of Breast Surgeons – http://www.breastsurgeons.org/officialstmts/officialstmt3.html

 

FCSO LCD 29052, Accelerated Partial Breast Irradiation (APBI), 02/02/2009. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

FDA Talk Paper. FDA Clears New Device for Radiation Treatment for breast cancer – http://www.fda.gov/bbs/topics/answers/2002/ANS01150.html

 

Fischer B, Anderson S, Bryant J, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med. 2002; 347:1233-1241.

 

Keisch M, Vicini F, Kuske RR, et al. Initial clinical experience with the MammoSite breast brachytherapy applicator in women with early-stage breast cancer treated with breast-conserving therapy. Int J Radiat Oncol Biol Phys 2003 Feb 1;55(2):289-93.

 

King TA, Bolton JS, Kuske RR, et al. Long-term results of wide-field brachytherapy as the sole method of radiation therapy after segmental mastectomy for T1,2 breast cancer. Am J Surg 2000 Oct;180(4):299-304.

 

Kuerer HM. The case for accelerated partial-breast irradiation for breast cancer. Contemporary Surgery 2003;59:508-517.

 

Morrow M. Rational local therapy for breast cancer. N Engl J Med 2002;347:1270-1271.

 

Newman, L. A. and T. A. Washington (2003). "New trends in breast conservation therapy." Surg Clin North Am 83(4): 841-83.

 

Polgar C, Sulyok Z, Fodor J, et al. Sole brachytherapy of the tumor bed after conservative surgery for T1 breast cancer: five-year results of a phase I-II study and initial findings of a randomized phase III trial. J Surg Oncol 2002 Jul;80(3):121-8.

 

Veronesi U, Cascinelli N, Mariani L, et al. Twenty-year follow-up of randomized study comparing breast-conserving surgery with radical (Halstead) mastectomy for early breast cancer. N Engl J Med. 2002; 347:1227-1232.

 

Vicini FA, Kestin L, Chen P, et al. Limited-field radiation therapy in the management of early-stage breast cancer. J Natl Cancer Inst 2003;95:1205-1211.

 

Wallner, P., D. Arthur, et al. (2004). "Workshop on partial breast irradiation: state of the art and the science, Bethesda, MD, December 8-10, 2002." J Natl Cancer Inst 96(3): 175-84.

 

 

AMA CPT Copyright Statement

CPT codes, descriptions and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

 

© Automated Clinical Guidelines, LLC 2009-2014

 

CMS LCD L28756 Accelerated Partial Breast Irradiation (APBI)