Clinical Policy: Radiation Therapy for Skin Cancer Form

CENTENE Corporation

Clinical Policy: Radiation Therapy for Skin Cancer Reference Number: CP.MP.251 Date of Last Revision: 08/25 Coding Implications Revision Log

See Important Reminder at the end of this policy for important regulatory and legal information.

Description Although surgical excision remains the primary treatment for skin cancer, radiation therapy serves an integral role in both definitive and adjuvant contexts.¹ Radiation therapy is a fundamental treatment modality for skin cancers, offering curative potential in members/enrollees who are not candidates for surgery and reducing the risk of recurrence and metastasis when used as adjuvant therapy.²

Note: For information regarding medical necessity for intensity-modulated radiotherapy (IMRT), please refer to CP.MP.69 Intensity-Modulated Radiotherapy.

CLINICAL POLICY Radiation Therapy for Skin Cancer

dimensional conformal radiation therapy) is medically necessary for the treatment of malignant cutaneous melanoma, when any of the following criteria are met: A. Definitive radiation therapy for melanoma in situ (MIS), lentigo maligna in medically inoperable members/enrollees or those in whom surgical morbidity of complete resection would be prohibitive; B. Definitive or palliative intent radiation for one of the following:

1. Unresectable nodal, satellite, or in-transit disease;
2. Residual local, satellite, or in-transit disease after prior treatment; C. Adjuvant radiation, one of the following:
3. High-risk resected regional disease with any of the following risk factors for regional recurrence: a. Extranodal extension in clinically involved nodes; b. ≥ one parotid lymph node of any size; c. ≥ two cervical or axillary nodes of any size; d. ≥ three inguinofemoral nodes of any size; e. ≥ 3 cm cervical or axillary node; f. ≥ 4 cm inguinofemoral node;
4. Distant metastatic disease that is widely disseminated with or without brain metastases;
5. Desmoplastic melanoma when there is a high risk of local recurrence.

III. It is the policy of health plans affiliated with Centene Corporation that the following procedures is considered not medically necessary in the treatment of any skin cancer, as there is insufficient data on long-term safety and efficacy: A. Electronic surface brachytherapy; B. Image guided superficial radiation therapy (IGSRT).

Background Skin cancer is the most prevalent cancer type in the United States with an incidence rate of over five million cases annually. Basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (cSCC) account for the majority of all skin cancer diagnoses and are the most treatable if caught early.³ Merkel cell carcinoma (MCC) is a less common skin cancer that can be aggressive and spread rapidly, making it more difficult to treat.⁴ Melanoma is a less common type of skin cancer, but it has a higher mortality rate and is considered particularly dangerous because it is much more likely to spread to other parts of the body if not detected and treated early.⁵ The primary treatment modality for skin cancer is surgical excision, but radiation therapy plays a key role for treatment in the definitive and adjuvant settings. Definitive radiation therapy, also called curative or primary radiation therapy, is used as the main treatment to eliminate cancer with curative intent. Adjuvant radiation therapy is a type of radiotherapy given after surgery to eliminate any remaining cancer cells that may not be visible but could still be present.⁶

Basal Cell Carcinoma (BCC) Surgery remains the standard and most effective treatment for BCC, however, primary radiation therapy can serve as an alternative in situations where surgery is not feasible, contraindicated, or refused by the patient following an informed discussion of risks and benefits. Primary or adjuvant radiation therapy represents an effective treatment option for selected patients with

CLINICAL POLICY Radiation Therapy for Skin Cancer

BCC, providing satisfactory tumor control and cosmetic outcomes, though cure rates might be lower. Adverse events following radiation therapy include acute radiation-induced skin toxicity, possible alterations to underlying tissues, and greater challenges in managing recurrences within the irradiated area. Late adverse effects may include alopecia, cartilage necrosis, pigmentation alterations of the skin, as well as an increased risk of secondary malignancies. The National Comprehensive Cancer Network (NCCN) offers guidance on both primary and adjuvant radiation therapy for BCC and cSCC, including dosing recommendations. It also advises consulting the American Society for Radiation Oncology (ASTRO) guideline on definitive and postoperative radiation therapy for basal and squamous cell cancers of the skin for general indications and dose recommendations.¹,⁷

Cutaneous Squamous Cell Carcinoma (cSCC) Although cSCC rarely metastasizes, it is the second most common skin cancer and can cause extensive local tissue damage, disfigurement, and invasion into soft tissue, cartilage, and bone. Treatment options are continually advancing to prevent disease recurrence and improve quality of life. While surgery remains the primary local treatment for cSCC, factors such as patient preference may lead to the selection of radiation therapy as the main treatment approach. The NCCN notes that when determining the appropriateness of radiation therapy, the decision should be made together with a radiation oncologist. Radiation as a primary therapy may be considered for patients who are not surgical candidates due to comorbidities, the extent of the disease, or risk of compromising function or cosmesis due to anatomical location of the tumor.⁸

Merkel cell carcinoma (MCC) MCC is a rare form of non-melanoma skin cancer that tends to grow quickly, metastasize early, and has a mortality rate higher than that of melanoma. Surgical excision is the principal therapeutic approach for most MCC and is essential for precise pathological assessment and staging of the primary tumor and regional involvement. Because of its propensity for rapid expansion, surgery has been the predominant approach for treating primary MCC tumors and has demonstrated improved outcomes relative to nonsurgical primary treatment. According to the NCCN, data on the effectiveness of definitive radiation therapy is limited; however, for patients with localized or regional MCC who are not surgical candidates or decline surgery, definitive radiation is likely to offer favorable outcomes.³ Additionally, if surgery is not feasible, definitive radiation therapy can be considered for nodal MCC in cases where there is a positive lymph node biopsy in the draining nodal basin without distant metastasis, when distant metastases are detected on clinical or radiologic evaluation, or when in-transit metastases are present.⁷ In-transit metastasis refers to the spread of skin cancer cells through lymphatic vessels, presenting secondary tumors more than two centimeters from the primary site but before reaching the regional lymph nodes.¹⁰ The NCCN offers recommendations on the use of adjuvant radiation therapy for MCC, aiming to lower the risk of local or regional recurrence after surgical removal.⁹

Cutaneous Melanoma The American Academy of Dermatology reports that over one million Americans are currently living with melanoma, and an estimated 212,200 new cases are expected to be diagnosed in the U.S. in 2025.¹¹ While surgical excision is the standard of care for in situ melanoma, it may not be feasible in cases involving comorbidities or tumors located in cosmetically sensitive areas. In certain cases, radiotherapy has also been utilized for the treatment of lentigo maligna.¹²

CLINICAL POLICY Radiation Therapy for Skin Cancer

Adjuvant radiation therapy is rarely indicated after complete excision of a primary melanoma. However, an exception may be desmoplastic neurotropic melanoma (DNM), due to its tendency to be locally aggressive. Adjuvant radiation therapy may also be appropriate for select patients with clinically positive lymph nodes and risk factors associated with a high likelihood of nodal basin recurrence. The NCCN panel extensively reviewed the role of adjuvant radiation therapy in patients at high risk of recurrence and reached a consensus that strong evidence supports its effectiveness in delaying or preventing nodal relapse. However, certain institutions contended that the higher risk of late toxicities associated with radiation therapy may outweigh the advantages of reducing nodal basin recurrence. Careful selection of patients, based on factors such as location, size, nodal involvement, and gross extramural extension instead of histologic assessment, is essential. Overall, when considering adjuvant radiation therapy, the potential benefits must be carefully weighed against the increased risk of chronic skin and regional side effects that can impair quality of life.¹²

Coding Implications This clinical policy references Current Procedural Terminology (CPT®, CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2024, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.

CLINICAL POLICY Radiation Therapy for Skin Cancer

CLINICAL POLICY Radiation Therapy for Skin Cancer

3. American Cancer Society. Key Statistics for Basal and Squamous Cell Skin Cancers. https://www.cancer.org/cancer/types/basal-and-squamous-cell-skin-cancer/about/key-statistics.html#~text=Cancers%200%20the%20skin%20most.from%20squamous%20cell%20skin%20cancer). Updated October 31, 2023. Accessed July 14, 2025.
4. American Cancer Society. What Is Merkel Cell Carcinoma (MCC)? https://www.cancer.org/cancer/types/merkel-cell-skin-cancer/about/what-is-merkel-cell-carcinoma.html. Published January 10, 2025. Accessed July 16, 2025.
5. American Cancer Society. What Is Melanoma Skin Cancer? https://www.cancer.org/cancer/types/melanoma-skin-cancer/about/what-is-melanoma.html. Published October 27, 2023. Accessed July 16, 2025.
6. American Cancer Society. Radiation Therapy for Basal and Squamous Cell Skin Cancers. https://www.cancer.org/cancer/types/basal-and-squamous-cell-skin-cancer/treating/radiation-therapy.html. Published October 13, 2023. Accessed July 16, 2025.
7. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Basal Cell Skin Cancer. Version 2.2025. https://www.nccn.org/professionals/physician_gls/pdf/nmsc.pdf. Updated February 07, 2025. Accessed July 07, 2025.
8. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Squamous Cell Skin Cancer. Version 2.2025. https://www.nccn.org/professionals/physician_gls/pdf/squamous.pdf. Updated February 07, 2025. Accessed July 07, 2025.
9. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Merkel Cell Carcinoma. Version 2.2025. https://www.nccn.org/professionals/physician_gls/pdf/mcc.pdf. Updated April 18, 2025. Accessed July 11, 2025.
10. National Cancer Institute. NCI dictionary of cancer terms: in-transit metastasis. https://www.cancer.gov/publications/dictionaries/cancer-terms/def/in-transit-metastasis. Accessed July 30, 2025.
11. American Academy of Dermatology. Skin Cancer. https://www.aad.org/media/stats-skin-cancer. Updated June 20, 2025. Accessed July 10, 2025.
12. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Melanoma: Cutaneous. Version 2.2025. https://www.nccn.org/professionals/physician_gls/pdf/cutaneous_melanoma.pdf. Updated January 28, 2025. Accessed July 10, 2025.

CLINICAL POLICY Radiation Therapy for Skin Cancer

13. Su W, Anstadt EJ, Gupta N, et al. Definitive Radiation Therapy is a Viable Treatment for Locally Advanced Basal Cell Carcinoma Otherwise Requiring Radical or Disfiguring Resection. Int J Radiat Oncol Biol Phys. 2025;121(3):677-683. doi:10.1016/j.ijrobp.2024.09.034
14. Health Technology Assessment. Superficial radiation therapy for treatment of nonmelanoma skin cancer. Hayes. www.hayesinc.com. Published March 21, 2018 (annual review June 04, 2020). Accessed July 03, 2025.
15. Aasi SZ, Hong AM. Treatment and prognosis of basal cell carcinoma at low risk of recurrence. UpToDate. www.uptodate.com. Updated May 07, 2025. Accessed July 03, 2025.
16. Muto P, Pastore F. Radiotherapy in the Adjuvant and Advanced Setting of CSCC. Dermatol Pract Concept. 2021;11(Suppl 2):e2021168S. Published 2021 Oct 1. doi:10.5826/dpc.11S2a168S
17. DeSimone JA, Hong AM, Ruiz ES, Jambusaria-Pahlajani A. Recognition and management of high-risk (aggressive) cutaneous squamous cell carcinoma. UpToDate. www.uptodate.com. Published March 17, 2025. Accessed July 14, 2025.
18. Dermatology Association of Radiation Therapy. Appropriate Use Criteria for the Treatment of Basal Cell Carcinoma (BCC) Using Image-Guided Superficial Radiation Therapy (Version 1.2024). https://dermassociationrt.org/wp-content/uploads/2024/08/AUC-BCC-Clinical-Guidelines-8-1-24.pdf. Published June 12, 2024. Accessed July 14, 2025.
19. Dermatology Association of Radiation Therapy. Appropriate Use Criteria for the Treatment of Early-Stage Cutaneous Squamous Cell Carcinoma (SCC) Using Image-Guided Superficial Radiation Therapy (Version 1.2024). https://dermassociationrt.org/wp-content/uploads/2024/06/AUC-SCC-Clinical-Guidelines-6-17-24.pdf. Published June 12, 2024. Accessed July 14, 2025.
20. Evidence Analysis Research Brief. Superficial radiation therapy for treatment of nonmelanoma skin cancer. Hayes. www.hayesinc.com. Published December 14, 2023. Accessed July 16, 2025.
21. Aasi SZ, Hong AM. Treatment and prognosis of low-risk cutaneous squamous cell carcinoma (cSCC). UpToDate. www.uptodate.com. Published June 18, 2025. Accessed July 03, 2025.