Hydrogel Spacer use During Radiotherapy for Prostate Cancer (ARCHIVED)

Policy ID: S-266-003

Section: Surgery

Effective Date: March 01, 2020

Revised Date: June 17, 2021

Revision Effective Date: May 02, 2022

Last Reviewed: March 23, 2022

Applies To: Commercial and Medicaid Expansion

This policy has been Archived effective May 02, 2022. Click the Archive tab above for more information.

Policy ID: S-266-003

Section: Surgery

Effective Date: March 01, 2020

Revised Date: June 17, 2021

Revision Effective Date: May 02, 2022

Last Reviewed: March 23, 2022

Archived Date: May 02, 2022

Applies To: Commercial and Medicaid Expansion

Description

For all risk groups of prostate cancer, radiation therapy is an option. Due to the fact that the rectum lies in proximity to the prostate, the risk of rectal toxicity is high. One approach is to push the rectum away from the prostate, increasing the space between the two and reducing the radiation does to the rectum. A variety of biomaterials, including polyethylene glycol hydrogels have been evaluated as perirectal spacers.

Criteria

Polyethylene-glycol (PEG) hydrogel may be considered medically necessary in individuals diagnosed with prostate cancer and are going to be treated with radiotherapy.

PEG not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

55874

Diagnosis Codes

C61

C79.82

D07.5

D40.0

Professional Statements and Societal Positions Guidelines

National Comprehensive Cancer Network - 2021

The National Comprehensive Cancer Network (v2.2021) provides the following recommendation in principles of radiation therapy, "Overall, the panel believes that biocompatible and biodegradable perirectal spacer materials may be implanted between the prostate and rectum in patients undergoing external radiotherapy with organ-confined prostate cancer in order to displace the rectum from high radiation dose regions."

ND Committee Review

Internal Medical Policy Committee 1-22-2020 New Policy

Internal Medical Policy Committee 3-17-2021 Annual Review-no changes

Internal Medical Policy Committee 7-22-2021 Removed diagnosis codes D29.1 and D49.59; added Professional Statements and Societal Positions Guidelines

Internal Medical Policy Committee 3-23-2022 Archiving policy - For services rendered on or after May 02, 2022, refer to Medical Policy S-275, Prostate Cancer: Diagnosis, Staging, and Treatment.

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

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