Radioembolization for Primary and Metastatic Tumors of the Liver

Policy ID: R-5043-02

Section: Radiation Therapy & Nuclear Medicine

Effective Date: March 01, 2020

Revised Date: January 22, 2020

Last Reviewed: January 19, 2021

Description

Treatments for Hepatic and Neuroendocrine Tumors

The use of external-beam radiotherapy and the application of more advanced radiotherapy approaches (e.g., intensity-modulated radiotherapy) may be of limited use in individuals with multiple diffuse lesions due to the low tolerance of the normal liver to radiation compared with the higher doses of radiation needed to kill the tumor.

Radioembolization

Radioembolization (referred to as selective internal radiotherapy in older literature) delivers small beads (microspheres) impregnated with yttrium-90 (Y90) intra-arterially via the hepatic artery. The microspheres, which become permanently embedded, are delivered to tumors preferentially because the hepatic circulation is uniquely organized, whereby tumors greater than 0.5 cm rely on the hepatic artery for blood supply while the normal liver is primarily perfused via the portal vein. Y90 is a pure beta-emitter with a relatively limited effective range and a short half-life that helps focus the radiation and minimize its spread.

Criteria

In general, radioembolizationis usedfor unresectable hepatocellular carcinoma that is greater than 3 cm.

There is little information on the safety or efficacy of repeated radioembolization treatments or on the number of treatments that shouldbe administered.

Radioembolization should be reserved for individuals with adequate functional status (Eastern Cooperative Oncology Group Performance Status 0-2), adequate liver function and reserve, Child-Pugh class A or B, and liver-dominant metastases.

Symptomatic disease from metastatic neuroendocrine tumors refers to symptoms related to excess hormone production.

Radioembolization may be considered medically necessary to treat primary hepatocellular carcinoma that is unresectable and limited to the liver;
Radioembolization may be considered medically necessary in primary hepatocellular carcinoma as a bridge to liver transplantation;
Radioembolization may be considered medically necessary to treat primary intrahepatic cholangiocarcinoma in individuals with unresectable tumors;
Radioembolization may be considered medically necessary to treat hepatic metastases from neuroendocrine tumors (carcinoid and noncarcinoid) with diffuse and symptomatic disease when systemic therapy has failed to control symptoms;
Radioembolization may be considered medically necessary to treat unresectable hepatic metastases from colorectal carcinoma, melanoma (ocular or cutaneous), or breast cancer that are both progressive and diffuse, in individuals with liver-dominant disease who are refractory to chemotherapy or are not candidates for chemotherapy or other systemic therapies.
Radioembolization is considered investigational for all other hepatic metastases except as noted above;
Radioembolization is considered investigational for all other indications not described above.

Procedure Codes

37243

75894

77399

77778

79445

C2616

S2095

Diagnosis Codes

C22.0

C78.7

Professional Statements and Societal Positions Guidelines

Practice Guidelines and Position Statements

National Comprehensive Cancer Network

Primary Hepatobiliary Carcinoma

The NCCN guidelines (v.1.2019) on the treatment of hepatobiliary carcinoma indicate that the use of arterially directed therapies, including transarterial bland embolization, transarterial chemoembolization, and drug-eluting beads transarterial chemoembolization, and RE with yttrium-90 microspheres may be appropriate provided that the arterial blood supply can be isolated without excessive nontarget treatment.

Metastatic Neuroendocrine Tumors

The NCCN guidelines (v.2.2019) on the treatment of neuroendocrine tumors give a category 2B recommendation for hepatic regional therapy (arterial embolization, chemoembolization, RE) in the setting of advanced locoregional disease.

Metastatic Colon Cancer

The NCCN guidelines (v.2.2019) on the treatment of colon cancer provides a consensus recommendation that: "…arterial-directed catheter therapy, in particular yttrium-90 microsphere selective internal radiation, is an option in highly selected individuals with chemotherapy-resistant/-refractory disease and with predominant hepatic metastases."

ND Committee Review

Internal Medical Policy Committee 1-22-2020 Annual Review

Internal Medical Policy Committee 1-19-2021 Annual Review

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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