G0458, Low dose rate (ldr) prostate brachytherapy services, composite rate
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Clinical treatment planning: "Documentation is required to report clinical treatment planning. Necessary documentation includes the diagnosis, treatment site, treatment intent, treatment dose, treatment technique and any special circumstances unique to the individual."
- General: "The radiation oncologist is responsible for documentation of IGRT directives, supervision, and review of all images."
- Simulation: "Appropriate documentation for simulation services includes: the treatment site, type of images, if a clinical simulation is performed, and any immobilization devices that are constructed. The documentation should be signed and dated by the physician."
- Respiratory simulation (+77293): "Documentation should include the medical necessity of reporting CPT® code +77293 and describe the work that was performed."
Key Coverage Criteria
- Clinical treatment planning (CPT® 77261, 77262, 77263): One unit of CPT® 77261, 77262, or 77263 is necessary for an episode of care (clinical treatment planning is performed after the initial consultation and before simulation).
- Simulation (CPT® 77280, 77285, 77290): For non-IMRT plans, one unit of CPT® 77280, 77285, or 77290 is allowed per phase of treatment; verification simulation reported with one unit of CPT® 77280. (+77293 respiratory motion management simulation is allowed when treatment area moves with continuous respiration and requires acquisition of multiple data sets.)
- Respiratory motion management simulation (CPT® +77293): Performed when the treatment area moves with continuous respiration; +77293 is an add-on code, allowed once per episode of care and only on same date of service as primary procedure (e.g., with 77295, 77301).
- Teletherapy isodose planning (CPT® 77306, 77307): One unit allowed for each treatment site approved when a teletherapy isodose plan has been authorized.
- 3-D conformal planning (CPT® 77295): One unit allowed per episode of care when 3-D conformal has been authorized.
- Special teletherapy plan (CPT® 77321): Allowed when an electron plan is performed.
8 Active Policies
EVICORE-RADIATION-ONCOLOGY-CODING-MANUAL, EviCore Radiation Oncology Coding Manual
CARELON-radiation-therapy-excludes-proton-2026-04-04, Radiation Therapy Excludes Proton
EVICORE-HPLAN-CIGNA-1815296EE67F, Cigna Comprehensive Code List - Effective 03/07/2026
EVICORE-HPLAN-CIGNA-08C913805997, Cigna Commercial Radiation Oncology Code List - Effective 03/07/2026
Related Codes
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