CPT 19294, in plain terms, covers Add-on for preparing the tumor cavity and placing an applicator for intraoperative radiation, done at the same session as partial mastectomy. CPT 19294 is referenced in 9 tracked payer policy changes from Anthem BCBS, Independence Blue Cross, and 3 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 19294 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Official descriptor: CPT 19294 on AAPC
Effective December 1, 2026, Anthem Blue Cross and Blue Shield in New York will require prior authorization through Carelon Medical Benefits Management for two intraoperative radiation therapy codes (CPT 19294 and 19297) used in breast cancer treatment. Billing teams must update workflows to obtain precertification before submitting claims for these procedures.
Effective December 1, 2026, Anthem Blue Cross and Blue Shield (Ohio) now requires precertification/prior authorization for two intraoperative radiation therapy CPT codes (19294 and 19297) used in breast cancer treatment. All requests for these codes must be submitted through Carelon Medical Benefits Management via their provider portal, Availity Essentials, or email before services are rendered.
Effective December 1, 2026, Anthem Blue Cross and Blue Shield (including HealthKeepers, Inc.) in Virginia now requires precertification/prior authorization for two radiation therapy CPT codes (19294 and 19297) related to intraoperative and interstitial radiotherapy during partial mastectomy procedures. All PPO and HMO commercial plans are affected. Billing teams must implement prior authorization requirements before this date or claims will be denied.
Effective December 1, 2026, Anthem Blue Cross and Blue Shield (Georgia) now requires prior authorization through Carelon Medical Benefits Management for two intraoperative radiation therapy (IORT) codes used in breast cancer treatment: CPT 19294 (tumor cavity preparation with IORT applicator) and CPT 19297 (radiotherapy catheter placement for interstitial radiation). All ordering and servicing providers must obtain precertification before these procedures are performed.
Independence Blue Cross updated policy 09.00.56w to align with revised EviCore Radiation Oncology Clinical Guidelines effective 02/25/2026. A substantial list of 57 new CPT and HCPCS codes has been added to Attachment A, expanding covered radiation therapy services including advanced techniques (IMRT, SBRT, SRS, proton therapy, brachytherapy) and radiolabeled drugs. Billing teams must update systems to recognize these newly covered codes and ensure claims are submitted with proper medical necessity documentation per eviCore guidelines.
Accelerated partial breast irradiation (APBI), including 3D conformal radiation therapy, intensity modulated radiation therapy, or multicatheter brachytherapy, may be considered medically necessary for individuals who have age at least 40, ER-positive histology, grade 1-2 disease, a tumor 2 cm or less, negative lymph nodes, negative surgical margins, and no known germline pathogenic or likely pathogenic BRCA 1 or BRCA 2 variant. The 08/25/2025 policy review changed APBI from investigational to medically necessary for these individuals. Accelerated whole-breast irradiation may be considered medically necessary for invasive carcinoma with tumors 5 cm or less, negative lymph nodes, technically clear surgical margins, and age at least 50, and it is investigational in all other situations involving early-stage breast cancer after breast-conserving surgery.
Excellus BlueCross BlueShield policy 6.01.30 covers interstitial or balloon brachytherapy of the breast as accelerated partial breast irradiation after breast-conserving surgery when either of two sets of criteria is met, and treats intra-operative breast radiotherapy and electronic brachytherapy as investigational. The 11/20/25 annual update made no changes to policy intent, termed code 0394T on 12/31/25, and added codes 77436, 77438 and 77439 effective 01/01/26, with code 77437 replacing 0394T. The current effective date of the policy is December 22, 2025.
Aetna Clinical Policy Bulletin 0721 sets Aetna's coverage rules for intraoperative radiation therapy (IORT). Aetna considers IORT medically necessary for cervical cancer, colorectal cancer, soft tissue sarcoma (including retroperitoneal sarcoma) and uterine cancer, and considers single-fraction electron-beam IORT at the time of lumpectomy medically necessary for breast cancer when the selection criteria are met. Aetna considers IORT experimental, investigational or unproven for brain tumors and brain metastasis, cholangiocarcinoma, conjunctival neoplasms, gastric cancer, glioma, head and neck cancers, osteosarcoma, pancreatic cancer, prostate cancer, renal cell carcinoma, spinal and vertebral metastases, sporadic renal angiomyolipoma and thymoma, and notes that this list is not all-inclusive.
Aetna considers intraoperative radiation therapy (IORT) medically necessary for cervical cancer, colorectal cancer, soft tissue sarcoma (including retroperitoneal sarcoma), and uterine cancer, and considers single-fraction electron-beam IORT at the time of lumpectomy medically necessary for breast cancer when the selection criteria are met. For breast cancer, the criteria are a documented diagnosis of early stage (0, I or II) breast cancer, negative lymph nodes, technically clear surgical margins, and a tumor less than or equal to 5 cm in diameter. IORT is considered experimental, investigational, or unproven for brain tumors and brain metastasis, cholangiocarcinoma, conjunctival neoplasms, gastric cancer, glioma, head and neck cancers, osteosarcoma, pancreatic cancer, prostate cancer, renal cell carcinoma, spinal metastases, sporadic renal angiomyolipoma, thymoma, and vertebral metastases (the list is not all-inclusive).
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