Provider Manual

Chapter 23: Radiation Therapy Program

This chapter contains policies and procedures for the EmblemHealth Radiation Therapy Program:

  • Cancer Clinical Pathways
  • Place of service for select outpatient radiation therapy services
  • Prior approval procedures
  • Urgent requests/non-urgent requests
  • Formal dispute resolution
  • CPT code list

On October 1, 2012, EmblemHealth instituted the EmblemHealth Radiation Therapy program. eviCore administers the program by conducting medical necessity reviews and authorizations, where applicable, for select outpatient radiation therapy services. eviCore also conducts clinical standard and expedited appeals (excluding members with Medicare plans).

Members in the following benefit plans are excluded from the program managed by eviCore. A prior approval request must be submitted to EmblemHealth at www.emblemhealth.com for radiation therapy services:

  • EmblemHealth Medicare Supplemental (Medicare Cost)
  • GHI CBP Program for City of New York Employees and Retirees
  • DC37 Med Team Program
  • EmblemHealth Medicare ASO (underwritten by GHI)
  • EmblemHealth EPO/PPO (underwritten by GHI)
  • HIP Prime® HMO and POS Plans for City of New York Employees
  • HIP and GHI FEHB plans
  • Vytra ASO accounts (underwritten by Vytra Health Plans Managed Systems)
  • Vytra HMO (underwritten by HIP)

 

Also excluded from this program are HIP members assigned to a Montefiore (CMO) or HealthCare Partners (HCP) PCP and members assigned to a PCP affiliated with AdvantageCare Physicians, as listed below.

 

AdvantageCare Physicians:

  • Manhattan's Physician Group
  • Preferred Health Partners
  • Queens-Long Island Medical Group
  • Staten Island Physician Practice

For applicable benefit plans, these members can be identified by their member ID card.

 

For members excluded from the Radiation Therapy program managed by eviCore, please refer to the Care Management chapter for information on how to obtain prior approval.

 

Prior approval must be obtained from eviCore for radiation therapy services performed on or after October 1, 2012. To submit prior approval requests, visit www.evicore.com or call eviCore at 1-866-417-2345 for plans underwritten by HIP or 1-800-835-7064 for GHI HMO and EmblemHealth Medicare PPO plans. Representatives are available Monday through Friday, from 7 am to 7 pm. Multiple requests can be handled with one call.

Services Requiring Prior Approval

All outpatient radiation therapy services require prior approval. eviCore has specific cancer clinical pathways, indicated below. For cancers less commonly treated with radiation therapy, the prior authorization follows an "Other Cancer Types" clinical pathway.

  • Bone Metastases
  • Brain Metastases
  • Breast Cancer
  • Cervical Cancer
  • Endometrial Cancer
  • Gastric Cancer
  • Head/Neck Cancer
  • Non-Cancerous Indications
  • Non-Small Cell Lung Cancer
  • Other Cancer Types
  • Pancreatic Cancer
  • Primary Central Nervous System Lymphoma
  • Primary Central Nervous System Neoplasms
  • Prostate Cancer
  • Rectal Cancer
  • Small Cell Lung Cancer

 

Each particular radiation treatment plan requires prior approval. Prior approvals are specific to the cancer type being treated. They have an expiration date based on the cancer diagnosis, treatment modality and the number of phases and fractions being requested. Prior approval must be obtained for radiation therapy treatment used to treat both malignant and benign indications.

 

Prior approval is required for services performed in the following places of service:

  • Ambulatory surgery centers (POS 24)
  • Freestanding radiology facilities (POS 11)
  • Outpatient facilities (POS 22)
  • Practitioner offices (POS 11)

 

Claims will be denied for procedures that require but did not receive prior approval or appropriate authorization through eviCore. In such cases, the member will not be held liable for billing or payment.

 

Who Requests Prior Approval

It is the responsibility of the referring practitioner (i.e., the practitioner developing the patient's treatment plan) to obtain the prior approval before services are rendered. If the referring practitioner and rendering practitioner are different, the rendering practitioner is encouraged to confirm that a prior approval is on file before services are rendered.

 

How To Request Prior Approval

Before requesting prior approval from eviCore, please have the medical records on hand and complete the form specific to the type of cancer being treated and the procedure being requested. These forms are available at the links below and at www.evicore.com. evieCore lists all clinical questions the practitioner must answer during the initial prior approval review.

  • Bone Metastases
  • Brain Metastases
  • Breast Cancer
  • Cervical Cancer
  • Endometrial Cancer
  • Gastric Cancer
  • Head/Neck Cancer
  • Non-Cancerous Indications
  • Non-Small Cell Lung Cancer
  • Other Cancer Types
  • Pancreatic Cancer
  • Primary Central Nervous System Lymphoma
  • Primary Central Nervous System Neoplasms
  • Prostate Cancer
  • Rectal Cancer
  • Small Cell Lung Cancer

 

Once the form is completed, submit prior approval requests in one of two ways:

  • Online: Visit www.evicore.com. To submit online requests, the ordering physician must be a registered user. To register for a user ID and password, visit www.evicore.com and select "Register."
  • By phone: Call 1-866-417-2345 for plans underwritten by HIP or 1-800-835-7064 for GHI HMO and EmblemHealth Medicare PPO plans. Representatives are available Monday through Friday, from 7 am to 7 pm. eviCore is closed New Year's Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, the Friday after Thanksgiving, and Christmas Day.

 

Expedited Prior Approval Requests

The eviCore website cannot be used for expedited approval requests. These requests must be processed through the eviCore call center. Call 1-866-417-2345 for plans underwritten by HIP or 1-800-835-7064 for GHI HMO and EmblemHealth Medicare PPO plans. eviCore utilization review staff is available 24 hours a day, 7 days a week. eviCore is closed New Year's Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, the Friday after Thanksgiving, and Christmas Day.

 

To expedite prior approvals, please have the following information on hand (please see forms at links above or at www.evicore.com:

  • Cancer type being treated with radiation therapy
  • Patient information
  • Ordering practitioner information
  • Rendering site information
  • Patient history
    • Recent test results
    • Work up
    • Current clinical condition
  • Treatment plan specifics, which may include:
    • Immobilization techniques
    • Treatment plan
    • Treatment technique
    • Fields/angles
    • Fractions
    • Boost

 

Urgent Requests

If the radiation treatment is medically urgent and must be performed outside eviCore's business hours, the physician may deliver treatment and must submit the prior approval request (with supporting clinical documentation) within two business days. Urgent requests are reviewed against medical necessity criteria, and an approval is issued as long as the request meets this criteria. Urgent requests will be completed within 24 hours of receiving the request.

 

The eviCore website cannot be used for urgent approval requests. These requests must be processed through the eviCore call center. Call 1-866-417-2345 for plans underwritten by HIP or 1-800-835-7064 for GHI HMO and EmblemHealth Medicare PPO plans. eviCore utilization review staff is available 24 hours a day, 7 days a week. eviCore is closed New Year's Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, the Friday after Thanksgiving, and Christmas Day.

 

Non-Urgent Requests

Non-urgent requests will be completed within three business days of receiving all necessary information. In most cases, eviCore will review and determine prior approvals during the initial phone call, as long as all the required information is provided. The review and determination processes may take longer if member or practitioner eligibility verification is required or if the request requires additional clinical review.

 

A physician with office hours later than eviCore's call center may initiate a case through eviCore's website. eviCore will process the request on the next business day.

 

Modifying Prior Approval Requests

If during a course of treatment the rendering physician opts to modify an approved treatment plan, the referring or rendering physician should call eviCore to discuss the new treatment plan. This allows eviCore to adjust the existing prior approval or create a new prior approval as needed. The referring or rendering physician must submit the supporting clinical history to determine medical necessity. The referring or rendering physician will then be notified as to whether the proposed changes to the treatment plan are deemed medically necessary. If the prior approval for the treatment plan is not updated and the claim does not match the authorized procedures, the claim will be denied for payment, with no liability to the member.

 

Prior Approval for Additional Treatment

The prior approval is valid for the approved treatment plan (an "episode of care"). If the member is provided with an additional episode of care, the referring and rendering physicians must communicate with eviCore about the member's care because a new prior approval will be required.

 

Verifying the Prior Approval Status

The practitioner who renders the services (e.g., the practitioner rendering the service at the outpatient hospital or ambulatory care center) is responsible for ensuring that the appropriate approval is on file. The appropriate staff at the location where services are rendered should verify the status of a prior approval request by calling 1-866-417-2345 for plans underwritten by HIP or 1-800-835-7064 for GHI HMO and EmblemHealth Medicare PPO plans.

 

You can also verify the prior approval request on the Authorization Lookup section of www.evicore.com. eviCore's prior approval determinations do not display at www.emblemhealth.com.

 

Please note that while eviCore may approve or deny a prior approval request, this determination is based on medical necessity only. Always verify member eligibility, benefits and copayments directly with EmblemHealth at www.emblemhealth.com.

 

Prior Approval Authorized Treatment

One prior approval is assigned per treatment plan. It includes the time frame for the treatment plan and any approved scans and simulations. Also, one prior approval number is assigned per course of treatment. This number applies to all services/CPT codes that are part of the approved treatment plan.

 

The prior approval letter includes the prior approval number, time frame the treatment is valid for, type of technique, number of phases, number of gantry angles, number of fractions, select CPT codes and claim instructions. If you have any questions about what is authorized, please call eviCore at 1-866-417-2345 for plans underwritten by HIP or 1-800-835-7064 for GHI HMO and EmblemHealth Medicare PPO plans.

 

Prior Approval Duration

The duration, or validity period, of a prior approval is communicated once the treatment plan is approved. If additional time is needed, the referring or rendering physician must contact eviCore to request an extension. The physician may contact eviCore's Clinical Review Department at 1-866-417-2345 for plans underwritten by HIP or 1-800-835-7064 for GHI HMO and EmblemHealth Medicare PPO plans. Claims will be denied for services performed without prior approval.

 

Determination Disagreement

If a referring or rendering physician disagrees with the eviCore determination, contact eviCore's Peer-to-Peer Consultation Line to discuss the case with a eviCore medical director. Call 1-866-417-2345 for plans underwritten by HIP or 1-800-835-7064 for GHI HMO and EmblemHealth Medicare PPO plans.

 

CPT Codes Requiring Prior Approval

The following CPT codes require prior approval for all plans covered by the EmblemHealth Radiation Therapy Program:

EmblemHealth Radiation Therapy Code List Effective October 1, 2012
CPT Code Procedure Description CPT Code Procedure Description
00330* RADIOLOGY/THERAPEUTIC – GENERAL CLASSIFICATION 77417 THERAPEUTIC RADIOLOGY PORT FILMS
00333* RADIOLOGY/THERAPEUTIC – RADIATION THERAPY 77418 IMRT TREATMENT DELIVERY; SINGLE OR MULTIPLE FIELDS/ ARCS, VIA NARROW SPATIALLY AND TEMPORARILY MODULATED BEAMS, BINARY, DYNAMIC MLC, PER TREATMENT SESSION
00339*  RADIOLOGY/THERAPEUTIC – OTHER 77421 STEREOSCOPIC X–RAY GUIDANCE FOR LOCALIZATION OF TARGET VOLUME
00344* THERAPEUTIC RADIOPHARMACEUTICALS 77422 HIGH ENERGY NEUTRON RADIATION TREATMENT DELIVERY; SINGLE TREATMENT AREA USING A SINGLE PORT OR PARALLEL-OPPOSED PORTS WITH NO BLOCKS OR SIMPLE BLOCKING
00973*  RADIOLOGY/THERAPEUTIC – PROFESSIONAL FEES
77423 HIGH ENERGY NEUTRON RADIATION TREATMENT DELIVERY; 1 OR MORE ISOCENTER(S) WITH COPLANAR OR NON-COPLANAR GEOMETRY WITH BLOCKING AND/OR WEDGE, AND/OR COMPENSATOR(S)
19296*  PLACEMENT OF RADIATION THERAPY AFTERLOADING EXPANDABLE CATHETER INTO THE BREAST FOR INTERSTITIAL RADIOELEMENT APPLICATION FOLLOWING PARTIAL MASTECTOMY, ON DATE SEPARATE FROM PARTIAL MASTECTOMY 77427 RADIATION TREATMENT MANAGEMENT, FIVE TREATMENTS
19297* PLACEMENT OF RADIATION THERAPY AFTERLOADING EXPANDABLE CATHETER INTO THE BREAST FOR INTERSTITIAL RADIOELEMENT APPLICATION FOLLOWING
PARTIAL MASTECTOMY, CONCURRENT WITH PARTIAL MASTECTOMY
77431 RADIATION TREATMENT MANAGEMENT, WITH COMPLETE COURSE OF THERAPY CONSISTING OF 1 –2 FRACTIONS ONLY
19298  PLACEMENT OF RADIATION THERAPY AFTERLOADING BRACHYTHERAPY CATHETER INTO THE BREAST FOR INTERSTITIAL RADIOELEMENT APPLICATION FOLLOWING PARTIAL MASTECTOMY
77432 STEREOTACTIC RADIATION TREATMENT MANAGEMENT CEREBRAL LESION(S) COMPLETE COURSE OF TREATMENT CONSISTING OF 1 SESSION
32553  PLACEMENT OF INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY GUIDANCE (E.G., FIDUCIAL MARKERS, DOSIMETER), PERCUTANEOUS, INTRA–THORACIC, SINGLE OR MULTIPLE 77435 STEREOTACTIC BODY RADIATION TREATMENT MANAGEMENT PER TREATMENT COURSE; 1 OR MORE LESIONS, INCLUDING IMAGE GUIDANCE ENTIRE COURSE NOT TO EXCEED 5 FRACTIONS
55920 PLACEMENT OF NEEDLES OR CATHETERS INTO PELVIC ORGANS AND/OR GENITALIA (EXCEPT PROSTATE) FOR SUBSEQUENT INTERSTITIAL RADIOELEMENT APPLICATION 77523 PROTON TREATMENT DELIVERY, INTERMEDIATE
57155 INSERTION OF UTERINE TANDEM AND/OR VAGINAL OVOIDS FOR CLINICAL BRACHYTHERAPY 77525 PROTON TREATMENT DELIVERY, COMPLEX
57156 INSERTION OF A VAGINAL RADIATION AFTERLOADING APPARATUS FOR CLINICAL BRACHYTHERAPY 77600 HYPERTHERMIA, EXTERNALLY GENERATED; SUPERFICIAL (I.E., HEATING TO A DEPTH OF 4 CM
OR LESS)
58346 INSERTION OF HEYMAN CAPSULES FOR CLINICAL BRACHYTHERAPY 77605 HYPERTHERMIA, EXTERNALLY GENERATED; DEEP (I.E., HEATING TO DEPTHS GREATER THAN 4 CM)
76950 ULTRASONIC GUIDANCE FOR PLACEMENT OF RADIATION THERAPY FIELDS 77610 HYPERTHERMIA GENERATED BY INTERSTITIAL PROBE(S); 5 OR FEWER INTERSTITIAL APPLICATORS
76965  ULTRASOUND GUIDANCE FOR INTERSTITIAL RADIOELEMENT APPLICATION 77615 HYPERTHERMIA GENERATED BY INTERSTITIAL PROBE(S); MORE THAN 5 INTERSTITIAL APPLICATORS
77011  COMPUTED TOMOGRAPHY GUIDANCE FOR STEREOTACTIC LOCALIZATION 77620 HYPERTHERMIA GENERATED BY INTRACAVITARY PROBES
77014  COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT OF RADIATION THERAPY FIELDS 77750 INFUSION OR INSTILLATION OF RADIOELEMENT SOLUTION (INCLUDES 3-MONTH FOLLOW-UP CARE)
77261 THERAPEUTIC RADIOLOGY TREATMENT PLANNING; SIMPLE 77761 INTRACAVITARY RADIATION SOURCE APPLICATION; SIMPLE
77262 THERAPEUTIC RADIOLOGY TREATMENT PLANNING; INTERMEDIATE 77762 INTRACAVITARY RADIATION SOURCE APPLICATION; INTERMEDIATE
77263  THERAPEUTIC RADIOLOGY TREATMENT PLANNING; COMPLEX 77763  INTRACAVITARY RADIATION SOURCE APPLICATION; COMPLEX
77280  THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; SIMPLE 77776 INTERSTITIAL RADIATION SOURCE; SIMPLE
77285 THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; INTERMEDIATE 77777 INTERSTITIAL RADIATION SOURCE; INTERMEDIATE
77290  THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; COMPLEX 77778 INTERSTITIAL RADIATION SOURCE; COMPLEX
77295  THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; 3-DIMENSIONAL 77785 REMOTE AFTERLOADING HIGH DOSE RATE RADIONUCLIDE BRACHYTHERAPY; 1 CHANNEL
77299  UNLISTED PROCEDURE; THERAPEUTIC RADIOLOGY CLINICAL TREATMENT PLANNING 77786 REMOTE AFTERLOADING HIGH DOSE RATE RADIONUCLIDE BRACHYTHERAPY; 2–12 CHANNELS
77300  BASIC RADIATION DOSIMETRY CALCULATION, CENTRAL AXIS DEPTH DOSE CALCULATION, TDF, NSD, GAP CALCULATION, OFF AXIS FACTOR, TISSUE INHOMOGENEITY FACTORS, CALCULATION OF NON-IONIZING RADIATION SURFACE AND DEPTH DOSE, AS REQUIRED DURING COURSE OF TREATMENT, ONLY WHEN PRESCRIBED BY THE TREATING PHYSICIAN 77787 REMOTE AFTERLOADING HIGH DOSE RATE RADIONUCLIDE BRACHYTHERAPY; OVER 12 CHANNELS
77301 INTENSITY MODULATED RADIOTHERAPY PLAN, INCLUDING DOSE-VOLUME HISTOGRAMS FOR TARGET AND CRITICAL STRUCTURE PARTIAL TOLERANCE SPECIFICATIONS 77789 SURFACE APPLICATION OF RADIATION SOURCE
77305 TELETHERAPY ISODOSE PLAN; SIMPLE 77790 SUPERVISION, HANDLING, LOADING OF RADIATION SOURCE
77310 TELETHERAPY ISODOSE PLAN; INTERMEDIATE 77799 UNLISTED PROCEDURE, CLINICAL BRACHYTHERAPY
77315  TELETHERAPY ISODOSE PLAN; COMPLEX 0073T  OMPENSATOR-BASED BEAM MODULATION TREATMENT DELIVERY OF INVERSE PLANNED TREATMENT USING 3 OR MORE HIGH RESOLUTION (MILLED OR CAST) COMPENSATOR CONVERGENT BEAM MODULATED FIELDS, PER TREATMENT SESSION
77321 SPECIAL TELETHERAPY PORT PLAN, PARTICLES, HEMIBODY, TOTAL BODY 0182T HIGH DOSE RATE ELECTRONIC BRACHYTHERAPY, PER FRACTION
77326  BRACHYTHERAPY ISODOSE PLAN; SIMPLE  0197T INTRA-FRACTION LOCALIZATION AND TRACKING OF TARGET OR PATIENT MOTION DURING DELIVERY OF RADIATION THERAPY (E.G., 3D POSITIONAL TRACKING, GATING, 3D SURFACE TRACKING), EACH FRACTION OF TREATMENT
77327 BRACHYTHERAPY ISODOSE PLAN; INTERMEDIATE C1715 BRACHYTHERAPY NEEDLE
77328  BRACHYTHERAPY ISODOSE PLAN; COMPLEX C1716 BRACHYTHERAPY SOURCE, NON-STRANDED, GOLD-198, PER SOURCE
77331  SPECIAL RADIATION DOSIMETRY C1717 BRACHYTHERAPY SOURCE, NON-STRANDED, GOLD-198 PER SOURCE
77332  TREATMENT DEVICES, DESIGN AND CONSTRUCTION; SIMPLE C1719 BRACHYTHERAPY SOURCE, NON-STRANDED, NONHIGH DOSE RATE IRIDIUM-192, PER SOURCE
77333  TREATMENT DEVICES, DESIGN AND CONSTRUCTION; INTERMEDIATE C1728 CATHETER, BRACHYTHERAPY SEED ADMINISTRATION
77334  TREATMENT DEVICES, DESIGN AND CONSTRUCTION; COMPLEX C2634 BRACHYTHERAPY SOURCE, NON-STRANDED, HIGH ACTIVITY, IODINE-124, GREATER THAN 1.01 MCI
77336  CONTINUING MEDICAL PHYSICS CONSULTATION C2635 BRACHYTHERAPY SOURCE, NON-STRANDED, HIGH ACTIVITY, PALLADIUM-103, GREATER THAN 2.2 MCI
77338  MULTI-LEAF COLLIMATOR (MLC) DEVICE(S) FOR INTENSITY MODULATED RADIATION THERAPY (IMRT), DESIGN AND CONSTRUCTION PER IMRT PLAN C2636 BRACHYTHERAPY LINEAR SOURCE, NON-STRANDED, PALADIUM-103, PER 1MM
77370  SPECIAL MEDICAL RADIATION PHYSICS CONSULTATION C2637 BRACHYTHERAPY SOURCE, NON-STRANDED, YTTERBIUM-169, PER SOURCE
77371  RADIATION TREATMENT DELIVERY, STEREOTACTIC RADIOSURGERY (SRS), COMPLETE COURSE OF TREATMENT OF CEREBRAL LESION(S) CONSISTING OF 1 SESSION, MULTI-SOURCE COBALT 60 BASED  C2638 BRACHYTHERAPY SOURCE, STRANDED, IODINE-125, PER SOURCE
77372  RADIATION TREATMENT DELIVERY, STEREOTACTIC RADIOSURGERY (SRS) COMPLETE COURSE OF TREATMENT OF CEREBRAL LESION(S) 1 CONSISTING OF SESSION, LINEAR ACCELERATOR BASED C2639 BRACHYTHERAPY SOURCE, NON-STRANDED, IODINE-125, PER SOURCE
77373  STEREOTACTIC BODY RADIATION THERAPY DELIVERY PER FRACTION 1 OR MORE LESIONS; INCLUDING IMAGE GUIDANCE, ENTIRE COURSE NOT TO EXCEED 5 FRACTIONS C2640 BRACHYTHERAPY SOURCE, STRANDED, PALLADIUM-103, PER SOURCE
77399  UNLISTED PROCEDURE, MEDICAL RADIATION PHYSICS, DOSIMETRY AND TREATMENT DEVICES, AND SPECIAL SERVICES C2641 BRACHYTHERAPY SOURCE, NON-STRANDED, PALLADIUM-103, PER SOURCE
77401  RADIATION TREATMENT DELIVERY; SUPERFICIAL AND/OR ORTHO VOLTAGE C2642 BRACHYTHERAPY SOURCE, STRANDED, CESIUM-131, PER SOURCE
77402  RADIATION TREATMENT DELIVERY; SINGLE TREATMENT AREA, SINGLE PORT OR PARALLEL OPPOSED PORTS, SIMPLE BLOCKS OR NO BLOCKS UP TO 5 MEV C2643 BRACHYTHERAPY SOURCE, NON-STRANDED, CESIUM -131, PER SOURCE
77403 RADIATION TREATMENT DELIVERY; SINGLE TREATMENT AREA, SINGLE PORT OR PARALLEL OPPOSED PORTS, SIMPLE BLOCKS OR NO BLOCKS; 11-19 MEV C2698 BRACHYTHERAPY SOURCE, STRANDED, NOT OTHERWISE SPECIFIED, PER SOURCE
77404 RADIATION TREATMENT DELIVERY; SINGLE TREATMENT AREA, SINGLE PORT OR PARALLEL OPPOSED PORTS, SIMPLE BLOCKS OR NO BLOCKS; 6-10 MEV C2699 BRACHYTHERAPY SOURCE, NON-STRANDED, NOT OTHERWISE SPECIFIED, PER SOURCE
77406  RADIATION TREATMENT DELIVERY; SINGLE TREATMENT AREA, SINGLE PORT OR PARALLEL OPPOSED PORTS, SIMPLE BLOCKS OR NO BLOCKS; 20 MEV AND GREATER C9725  LACEMENT OF ENDORECTAL INTRACAVITARY APPLICATOR FOR HIGH INTENSITY BRACHYTHERAPY
77407  RADIATION TREATMENT DELIVERY; TWO SEPARATE TREATMENT AREAS, THREE OR MORE PORTS ON A SINGLE TREATMENT AREA USE OF MULTIPLE BLOCKS; UP TO 5 MEV C9726 PLACEMENT AND REMOVAL (IF PERFORMED) OF APPLICATOR INTO BREAST FOR RADIATION THERAPY
77408  RADIATION TREATMENT DELIVERY; TWO SEPARATE TREATMENT AREAS, THREE OR MORE PORTS ON A SINGLE TREATMENT AREA USE OF MULTIPLE BLOCKS; 6-10 MEV C9728  LACEMENT OF INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY/ SURGERY GUIDANCE (E.G., FIDUCIAL MARKERS, DOSIMETER), OTHER THAN ABDOMEN, PELVIS, PROSTATE, RETROPERITONEUM, THORAX (ANY APPROACH), SINGLE OR MULTIPLE
77409  RADIATION TREATMENT DELIVERY; TWO SEPARATE TREATMENT AREAS, THREE OR MORE PORTS ON A SINGLE TREATMENT AREA USE OF MULTIPLE BLOCKS; 11-19 MEV G0173 LINEAR ACCELERATOR BASED STEREOTACTIC RADIOSURGERY, COMPLETE COURSE OF THERAPY IN ONE SESSION
77411  RADIATION TREATMENT DELIVERY; TWO SEPARATE TREATMENT AREAS, THREE OR MORE PORTS ON A SINGLE TREATMENT AREA USE OF MULTIPLE BLOCKS; 20 MEV OR
GREATER
G0251 LINEAR ACCELERATOR BASED STEREOTACTIC RADIOSURGERY, DELIVERY INCLUDING COLLIMATOR CHANGES AND CUSTOM PLUGGING, FRACTIONATED TREATMENT, ALL LESIONS, PER SESSION, MAXIMUM FIVE SESSIONS PER COURSE OF TREATMENT
77412  RADIATION TREATMENT DELIVERY; THREE OR MORE SEPARATE TREATMENT AREAS; CUSTOM BLOCKING, TANGENTIAL PORTS WEDGES, ROTATIONAL BEAM, COMPENSATORS, ELECTRON BEAM; UP TO 5 MEV G0339  IMAGE-GUIDED ROBOTIC LINEAR ACCELERATORBASED STEREOTACTIC RADIOSURGERY, COMPLETE COURSE OF THERAPY IN ONE SESSION OR FIRST SESSION OF FRACTIONATED TREATMENT
 77413  RADIATION TREATMENT DELIVERY; THREE OR MORE SEPARATE TREATMENT AREAS; CUSTOM BLOCKING, TANGENTIAL PORTS WEDGES, ROTATIONAL BEAM, COMPENSATORS, ELECTRON BEAM; 6-10 MV COMPLEX G0340 IMAGE-GUIDED ROBOTIC LINEAR ACCELERATOR-BASED STEREOTACTIC RADIOSURGERY, DELIVERY INCLUDING COLLIMATOR CHANGES AND CUSTOm PLUGGING, FRACTIONATED TREATMENT, ALL LESIONS, PER SESSION, SECOND THROUGH FIFTH SESSIONS, MAXIMUM FIVE SESSIONS PER COURSE OF TREATMENT
77414 RADIATION TREATMENT DELIVERY; THREE OR MORE SEPARATE TREATMENT AREAS; CUSTOM BLOCKING, TANGENTIAL PORTS WEDGES, ROTATIONAL BEAM, COMPENSATORS, ELECTRON BEAM; 11-19 MV COMPLEX Q3001 BRACHYTHERAPY RADIOELEMENTS
77416 RADIATION TREATMENT DELIVERY; THREE OR MORE SEPARATE TREATMENT AREAS; CUSTOM BLOCKING, TANGENTIAL PORTS WEDGES, ROTATIONAL BEAM,
COMPENSATORS, ELECTRON BEAM; 20 MV OR GREATER 
S8030 SCLERAL APPLICATION OF TANTALUM RING(S) FOR LOCALIZATION OF LESIONS FOR PROTON BEAM THERAPY
 * Covered if billed with an appropriate CPT code.

 

Formal Dispute Resolution

Please submit to EmblemHealth:

 

Please submit to eviCore:

  • Expedited and standard clinical appeals for Commercial/Child Health Plus members and expedited and standard action appeals for Medicaid members. Appeals may be filed by the member, the member's delegate (including the practitioner acting as the member's delegate) or the practitioner on his or her own behalf. For a full description of member and practitioner rights regarding clinical and action appeals, see the Dispute Resolution chapters for Commercial/CHP and Medicaid, as applicable.