77772
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
5.27
Facility
$914.85
Non-Facility
$914.85
Documentation Required
- When billing CPT codes cited as 'covered if selection criteria are met', documentation should support that selection criteria were met (diagnosis, prior treatments, timing as applicable).
- Use of TRASER or ablative radiotherapy for the listed experimental indications should be documented as investigational if attempted (policy states these are experimental/investigational and effectiveness not established).
- For prevention of heterotopic ossification: documentation that the person is "identified as being at high risk (previous heterotopic ossification, ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis or spinal stenosis, unlimited hip motion preoperatively, and head injury)."
- For Ledderhose disease: documentation of prior conventional treatments tried and failed (e.g., tamoxifen, verapamil, steroid injections) before proceeding to radiation therapy.
Key Coverage Criteria
- Aetna considers low-dose or high-dose radiation (superficial or interstitial) medically necessary as an adjunctive therapy immediately following excisional surgery (within 7 days) in the treatment of keloids where medical necessity criteria for keloid removal are met. See CPB 0031 - Cosmetic Surgery for medically necessary indications for keloid removal.
- Aetna considers use of beta irradiation medically necessary for prevention of primary or recurrent pterygium in cases that cannot be managed medically.
- Aetna considers radiation therapy medically necessary for the prevention of heterotopic ossification in persons identified as being at high risk (previous heterotopic ossification, ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis or spinal stenosis, unlimited hip motion preoperatively, and head injury).
- Aetna considers radiation therapy medically necessary for the treatment of Ledderhose disease (plantar fibromatosis) when conventional treatments (e.g., tamoxifen, verapamil and steroid injections) have failed.
- CPT codes covered if selection criteria are met: 77401 - 77417 (Radiation treatment delivery [includes beta irradiation]); 77767 - 77772 (Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when performed); 77778 (Interstitial radiation source application, complex, includes supervision, handling, loading of radiation source, when performed).
- ICD-10 codes covered if selection criteria are met: L91.0 (Hypertrophic scar [keloid]); M08.1; M45.0 - M45.9 (Ankylosing spondylitis); M48.00 - M48.08 (Spinal stenosis); M72.2 (Plantar fascial fibromatosis); S06.0x0+ - S06.9x9+ (Intracranial injury).
7 Active Policies
AMBETTER-CP.MP.251 — Radiation Therapy for Skin Cancer
CARELON-radiation-therapy-excludes-proton-2025-03-23 — Radiation Therapy Excludes Proton
EVICORE-RADIATION_ONCOLOGY-79FF8D84 — EviCore Radiation Oncology Coding Guidelines
EVICORE-RADIATION-ONCOLOGY-CODING-MANUAL — EviCore Radiation Oncology Coding Manual
Related Codes
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