Indications and Limitations of Coverage and/or Medical Necessity
Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered.
Grenz rays are ultrasoft and super-soft radiation that are produced at low kilovoltages (5-20) and are usually delivered at a target skin value filtration thickness of 1-2 mm. Due to their very limited depth of penetration, Grenz rays have a low potential for radiation damage when proper safety measures are followed. Grenz Ray Treatment (GRT) is appropriate when other simpler methods (e.g., creams, lotions, ointments or pills) have failed.
Grenz ray therapy may be indicated as an adjunct to usual therapeutic modalities in the conditions listed below. It should not be considered as the first treatment of choice, but rather considered when other recommended therapies have failed.
Because GRT has a low potential for radiation damage, in contrast to traditional external beam or brachytherapy, and because GRT is directed at a visible lesion in contrast to internal malignancies, the CPT codes used by the radiation oncologist (77261–77470) do not apply to, are not appropriate for and may not be billed for GRT. The initial evaluation and determination of the treatment plan and the evaluation of the effect of treatment may be billed with an E/M service code.
Superficial radiation therapy of the skin for the treatment of malignant lesions (CPT 77401) or any of the other associated radiology services codes should not be confused with Grenz ray and should not be billed for Grenz ray treatments.
Also, CPT code 96900©, actinotherapy (ultraviolet light), must not be confused with GRT and should not be billed for GRT.
Compliance with the provisions in this policy is subject to monitoring by post payment data analysis and subsequent medical review.
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
  • Safe and effective.
  • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
  • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient’s medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient’s medical need.
    • At least as beneficial as an existing and available medically appropriate alternative.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
12X, 13X, 85X
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Claims Processing Manual, for further guidance.
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
Radiation therapy management
ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS code 77499:
Covered for:
Other malignant neoplasm of skin
Note: Use codes 173.0–173.9 for basal cell carcinomas.
Mycosis fungoides
Neoplasm of unspecified nature of bone soft tissue and skin
Note: Use code 239.2 for Bowen’s disease.
Other specified disorders of metabolism
Note: Use code 277.89 for Langerhans’ cell histiocytosis.
Other atopic dermatitis and related conditions
Contact dermatitis and other eczema
Due to other specific agents
Contact dermatitis and other eczema due to other specified agents
Contact dermatitis and other eczema unspecified cause
Psoriasis and similar disorders
Pityriasis rubra pilaris
Lichen planus
Pruritus and related conditions
Lichenification and lichen simplex chronicus
Other alopecia
Other specified congenital anomalies of skin
Note: Use code 757.39 for Darier’s disease and benign chronic familial pemphigus.
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
Diagnoses That Support Medical Necessity
ICD-9-CM Codes That DO NOT Support Medical Necessity
Diagnoses That DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.
Documentation Requirements
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
In the clinical record, the Grenz radiation dose must be expressed in Roentgens, rads, gray (Gy) or centiGy.
Utilization Guidelines
The usual course of treatment consists of weekly or bi-weekly treatments over three or four sessions, but the frequency varies greatly and depends on the type and extent of the lesion(s). Subsequent treatments may be repeated two or three times yearly, if needed.
Notice: This LCD imposes utilization guideline limitations. Despite Medicare’s allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient’s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services.
Sources of Information and Basis for Decision
J4 (CO, NM, OK, TX) MAC Integration
TrailBlazer adopted the Noridian Administrative Services, LLC LCD, “Grenz Ray Treatment,” for the Jurisdiction 4 (J4) MAC transition.
Full disclosure of sources of information is found with original contractor LCD.
Other Contractor Local Coverage Determinations
“Grenz Ray Treatment,” Noridian Administrative Services, LLC LCD, (CO) L23814.
Start Date of Notice Period
Revision History
Per CR 7121 (annual HCPCS update), description changed for the GA modifier. Effective date: 01/01/2011.
Use of LCD and related article made applicable to providers transitioning from WPS to TrailBlazer with addition of contractor number 04901. Effective date: dates of service on or after 10/18/2010.
LCD effective in TX Part A and Part B and Part A CO and NM 06/13/2008
LCD effective in CO Part B 03/21/2008
LCD effective in NM Part B and OK Part A and Part B 03/01/2008
Consolidated LCD posted for notice effective: 12/20/2007