Does not apply to Medicare Advantage. Please refer to the LCD (L30320) on Brachytherapy.
DESCRIPTION
Intracavitary balloon catheter brain brachytherapy is localized radiation therapy in the brain that requires placement of an inflatable balloon catheter in the surgical cavity that results from the removal or debulking of a malignant brain mass. A radiation source is then placed in the balloon to expose surrounding brain tissue to radiation, either continuously or in a series of brief treatments. After the patient completes therapy, the radiation source is permanently removed and the balloon catheter is surgically explanted.
POLICY
Intracavitary balloon catheter brain brachytherapy alone or as part of a multimodality treatment regimen, for primary or recurrent malignant brain tumors is considered investigational.
Intracavitary balloon catheter brain brachytherapy alone or as part of a multimodality treatment regimen, for metastasis to the brain from primary solid tumors outside the brain is considered investigational.
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
This policy does not apply to Medicare Advantage. Please refer to the LCD (L30320) on Brachytherapy.
ADDITIONAL INFORMATION
The standard medical care for primary brain malignancies or brain metastases of solid tumors has not been established. To date there are no clinical results available to provide convincing evidence that intracavitary balloon brachytherapy extends the duration of survival, time-to-relapse, quality of life, or time-to-progression.
SOURCES
BlueCross BlueShield Association. Medical Policy Reference Manual. (4:2011). Intracavitary balloon catheter brain brachytherapy for malignant gliomas or metastasis to the brain. (8.01.45). Retrieved June 7, 2011 from BlueWeb. (15 articles and/or guidelines reviewed)
Chan, T., Weingart, J., Parisi, M., Hughes, M., Olivi, A., Borzillart, S., et al. (2004) Treatment of recurrent glioblastoma multiforme with Gliasite brachytherapy. International Journal of Radiation Oncology, Biology, and Physics, 62 (4), 1133-1139. (Level 4 Evidence - Industry sponsored)
National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology™. Central Nervous System Cancers (V.2.2011). Retrieved June 7, 2011 from http://www.nccn.org/professionals/physician_gls/pdf/cns.pdf.
U. S. Food and Drug Administration. (2009. July). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K003206. Retrieved June 7, 2011 from http://www.accessdata.fda.gov/cdrh_docs/pdf/K003206.pdf.
U. S. Food and Drug Administration. (2009. July). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K090914. Retrieved June 7, 2011 from http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=30673.
Wernicke, A., Sherr, D., Schwartz, T., Panullo, S., Stieg, P., Bookvar, J., et al. (2010) Feasibility and safety of GliaSite brachytherapy in the treatment of CNS tumors following neurosurgical resection. Journal of Cancer Research and Therapeutics, 6 (1), 65-74. (Level 4 Evidence)
Winifred S. Hayes. Medical Technology Directory. (2006, December). Brachytherapy for malignant gliomas. Retrieved June 7, 2011 from www.Hayesinc.com/subscribers. (55 articles and/or guidelines reviewed)
ORIGINAL EFFECTIVE DATE: 12/10/2011
MOST RECENT REVIEW DATE: 12/10/2011
ID_BA
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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