Notification of Policy Revision Effective April 17, 2024 (Posted February 6, 2024) | Providers

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Notification of Policy Revision Effective April 17, 2024 (Posted February 6, 2024)

Medical Policy	Revision
Perirectal Spacer Use During Radiotherapy for Prostate Cancer - Going on Notification	Off cycle review to add not medically necessary statement for proton beam therapy. Under “when not covered” section added: “Transperineal placement of a biodegradable, perirectal spacer (ie SpaceOAR) is considered not medically necessary in individuals undergoing proton beam therapy for treatment of prostate cancer.” References added. Medical Director review 1/2024. Notification given 2/6/24 for effective date 4/17/24.

Medical Policy

Revision

Perirectal Spacer Use During Radiotherapy for Prostate Cancer - Going on Notification

Off cycle review to add not medically necessary statement for proton beam therapy. Under “when not covered” section added: “Transperineal placement of a biodegradable, perirectal spacer (ie SpaceOAR) is considered not medically necessary in individuals undergoing proton beam therapy for treatment of prostate cancer.” References added. Medical Director review 1/2024. Notification given 2/6/24 for effective date 4/17/24.

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