Effective Date:

May 23, 2021

Purpose:

To provide guidelines for the reimbursement of brachytherapy for professional providers and outpatient facilities.

Scope:

Products included:

• NJ FamilyCare/Medicaid
• Fully Integrated Dual Eligible Special Needs Program (FIDE-SNP)

Policy:

Brachytherapy is a form of radiotherapy where a sealed radiation source is placed inside or next to the area requiring treatment. Brachytherapy testing must adhere to Horizon NJ Health’s medical policy guidelines.

Claims for brachytherapy radiation sources must have an associated claim for the brachytherapy procedure in order to be eligible for reimbursement.

CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

Procedure:

Horizon NJ Health will not consider for reimbursement claims for the associated brachytherapy radiation source when there is not an associated brachytherapy procedure code.

Resources:

American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services

Limitations and Exclusions:

Notwithstanding the foregoing, all payment determinations are subject to all other, applicable limitations, including but not limited to, the following:

• Benefit Limitations
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.