Anthem Blue Cross Connecticut CG-THER-RAD-07 Intravascular Brachytherapy (Coronary and Non-Coronary) Form

This document addresses the use of intravascular brachytherapy for treatment of vascular disease. This document does not address the use of intravascular brachytherapy to treat oncologic conditions.

Clinical Indications

Medically Necessary:

Intravascular coronary brachytherapy, also called intracoronary brachytherapy, is considered medically necessary as a treatment of in-stent restenosis.

Not Medically Necessary:

Intravascular coronary brachytherapy is considered not medically necessary for all other uses not specified above as medically necessary, including, but not limited to, the following:

• As an initial treatment of coronary artery disease to prevent de novo stenosis either within or adjacent to stent placement
• Repeat intracoronary brachytherapy

Non-coronary intravascular brachytherapy is considered not medically necessary for the treatment or prevention of stenosis or restenosis in blood vessels, including, but not limited to, the femoropopliteal vessels.