BlueCross BlueShield of Tennessee Medical Policy Manual

Radioembolization for Primary Tumors of the Liver and Metastatic Tumors to the Liver

Does not apply to Medicare members, please refer to the Medicare policy addressing this topic.

DESCRIPTION

Radioactive yttrium-90 microspheres offer a selective internal radiation therapy (SIRT), also referred to as radioembolization, transarterial radioembolization [TARE] or brachytherapy, for primary and metastatic tumors to the liver. A trained specialist injects radioactive microspheres into hepatic arteries that supply blood to tumor(s).

The goal of the procedure is to irradiate and destroy the tumor(s) while sparing normal liver tissue.

Hepatic (liver) tumors can arise either as primary liver cancer or by metastasis to the liver from other tissues or organs. Surgical resection is presently the treatment of choice for hepatic tumors. Unfortunately, most hepatic tumors are unresectable at diagnosis. This is due either to the tumors anatomic location, size (>3cm.), number of lesions, concurrent nonmalignant liver disease, or insufficient hepatic reserve.

At the present time two forms of yttrium-90 impregnated microspheres are commercially available. TheraSphere® is FDA approved under a Humanitarian Device Exemption. SIR-Spheres® have premarket approval for use in combination with hepatic artery infusion chemotherapy to treat unresectable hepatic metastatic colorectal cancer.

POLICY

Radioembolization for the treatment of primary hepatocellular carcinoma or hepatic metastases is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)

See also:  

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

Child-Pugh score is a scoring system for liver function based on the presence of encephalopathy and/or ascites, and laboratory measures of bilirubin, albumin, and prothrombin time.

Eastern Cooperative Oncology Group (ECOG) performance scales assess how an individual’s disease is progressing, how the disease affects the daily living abilities of the individual, and guides appropriate treatment and prognosis.

SOURCES

American College of Radiology. (2015). ACR appropriateness criteria ® radiologic management of hepatic malignancy. Retrieved June 7, 2016 from the National Guideline Clearinghouse (NGC: 010833).

Bhooshan, N., Sharma, N., Badiyan, S., Kaiser, A., Moeslein, F., Kwok, Y., et al. (2016). Pretreatment tumor volume as a prognostic factor in metastatic colorectal cancer treated with selective internal radiation to the liver using yttrium-90 resin microspheres. Journal of Gastrointestinal Oncology, 7 (6), 931-937. Abstract retrieved May 3, 2017 from PubMed database.

BlueCross BlueShield Association. Medical Policy Reference Manual. (7:2016). Radioembolization for primary and metastatic tumors of the liver (8.01.43). Retrieved May 6, 2017 from BlueWeb. (74 articles and/or guidelines reviewed)

Cucchetti, A., Cappelli, A., Mosconi, C., Zhong, J., Cescon, M., Pinna, A., & Golfieri, R. (2017). Improving patient selection for selective internal radiation therapy of intra-hepatic cholangiocarcinoma: a meta-regression study. Liver International, 2017 Feb 8. Doi: 10.1111/liv.13382 [Epub ahead of print]. Abstract retrieved May 3, 2017 from PubMed database.

National Comprehensive Cancer Network. (2017, March). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Colon cancer. V.2.2017. Retrieved May 3, 2017 from the National Comprehensive Cancer Network.

National Comprehensive Cancer Network. (2017, March). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Hepatobiliary cancers. V.1.2017. Retrieved May 3, 2017 from the National Comprehensive Cancer Network.

National Comprehensive Cancer Network. (2017, March). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®).Neuroendocrine tumors. V.2.2017. Retrieved May 3, 2017 from the National Comprehensive Cancer Network.

National Institute for Health and Care Excellence. (2011, July) Selective internal radiation therapy for nonresectable colorectal metastases in the liver. Retrieved June 7, 2016 from www.nice.org.uk.

U. S. Food and Drug Administration. (2002, March) Center for Devices and Radiological Health. Pre-market approval decision for March 2002 P990065A. Retrieved June 7, 2016 from http://www.fda.gov.

Winifred S. Hayes, Inc. Medical Technology Directory. (2014, October; last update search September 2016). Radioactive Yttrium-90 microspheres for treatment of primary unresectable liver cancer. Retrieved May 3, 2017 from www.Hayesinc.com/subscribers  (72 articles and/or guidelines reviewed)

Winifred S. Hayes, Inc. Medical Technology Directory. (2014, October; last update search October 2016). Radioactive Yttrium-90 microspheres for treatment of primary unresectable liver cancer as a bridge to transplantation or surgery. Retrieved May 3, 2017 from www.Hayesinc.com/subscribers   (70 articles and/or guidelines reviewed)

Winifred S. Hayes, Inc. Medical Technology Directory. (2015, March; last update search March 2017). Radioactive Yttrium-90 microspheres for treatment of secondary liver cancer. Retrieved June 7, 2016 from May 3, 2017 from www.Hayesinc.com/subscribers   (94 articles and/or guidelines reviewed)

ORIGINAL EFFECTIVE DATE:  1/1/2005

MOST RECENT REVIEW DATE:  6/8/2017

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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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