S2095 — Transcatheter occlusion or embolization for tumor destruction, percutaneous, any method, using yttrium-90 microspheres
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Documentation Required
- Documentation of candidacy for surgery / statement that the patient is not a surgical candidate (policy history added 'candidacy for surgery').
- Imaging to establish diagnosis, disease distribution and liver-dominant disease (contrast-enhanced liver protocol CT or MRI to determine lesion burden and identify imaging factors such as ascites).
- Documentation of tumor site and type of primary malignancy and metastatic lesion(s) (policy history: 'site and type of primary malignancy and metastatic lesion(s)').
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage.
Key Coverage Criteria
- This policy applies to individuals 19 years of age and older. Transarterial Radioembolization/selective internal radiation therapy is covered without further review for individuals younger than 19 years of age.
- Transarterial Radioembolization (TARE)/selective internal radiation therapy (SIRT) using yttrium-90 microspheres is proven and medically necessary for the following indications in individuals with an Eastern Cooperative Oncology Group (ECOG) Performance Status of 0, 1, or 2:
- Liver dominant primary hepatocellular carcinoma (HCC) in individuals who are not surgical candidates
- Primary hepatocellular carcinoma as a bridge to liver transplantation
- Liver metastases from neuroendocrine tumors in individuals who are not surgical candidates when systemic therapy has failed to control symptoms
- Liver metastases from colorectal carcinoma in individuals with chemotherapy-resistant or Refractory disease and with predominant hepatic metastases
5 Active Policies
EVICORE-RADIATION-ONCOLOGY-CODING-MANUAL — EviCore Radiation Oncology Coding Manual
ANTHEM-CG-SURG-78 — CG-SURG-78 Cryosurgical, Radiofrequency, Microwave, or Percutaneous Ethanol Ablation to Treat Solid Tumors in the Liver
UHC-POL-transarterial-radioembolization — Transarterial Radioembolization (TARE)/ Selective Internal Radiation Therapy (SIRT) for the Treatment of Malignant Cancers of the Liver
UMR-POL-UMR-transarterial-radioembolization — Transarterial Radioembolization (TARE)/ Selective Internal Radiation Therapy (SIRT) for the Treatment of Malignant Cancers of the Liver
Related Codes
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