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Hydrogel Spacer use During Radiotherapy for Prostate Cancer

Section: Surgery
Effective Date: March 01, 2020
Last Reviewed: January 22, 2020

Description

For low or intermediate risk 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 who are undergoing radiotherapy and have been diagnosed with prostate cancer.

PEG will be considered experimental/investigational and therefore non-covered for all other indications due to lack of supporting published peer reviewed literature.

Procedure Codes

55874

Diagnosis Codes

C61 C79.82 D07.5 D29.1 D40.0 D49.59

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