CPT 19297, in plain terms, covers Add-on for placing an expandable radiation afterloading catheter into the breast at the same session as a partial mastectomy. CPT 19297 is referenced in 11 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 19297 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Official descriptor: CPT 19297 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.
Independence Blue Cross reissued Policy 09.00.10aa with CPT code updates effective 01/01/2026. Three new CPT codes (77436, 77437, 77439) were added as experimental/investigational for brachytherapy procedures, and obsolete CPT code 0394T was removed. No changes to coverage criteria or medical necessity guidelines occurred.
Independence Administrators reissued policy 09.00.10aa with CPT code updates effective 01/01/2026. Three new experimental/investigational CPT codes (77436, 77437, 77439) were added for brachytherapy and accelerated whole breast irradiation, and one terminated code (0394T) was removed. No changes to coverage criteria or medical necessity determinations were made.
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 considers brachytherapy medically necessary for breast, esophageal, eye tumors, genitourinary cancers other than bladder, gynecologic, head and neck, respiratory and digestive tract, and soft tissue sarcoma indications when the EviCore Healthcare Radiation Therapy Clinical Guidelines criteria are met. It also considers brachytherapy medically necessary for skin cancer where surgical resection and photon or electron beam techniques are contraindicated, and for stenotic obstruction after lung transplantation refractory to other treatments. Brachytherapy for bladder cancer, bone metastases, brain tumors, leukemia, lymphoma, multiple myeloma, pancreatic cancer, keloids, palmoplantar pustulosis, spinal tumors and spinal metastases, and subfoveal choroidal neovascularization secondary to age-related macular degeneration is considered experimental, investigational or unproven, and electronic brachytherapy is considered experimental, investigational or unproven for breast cancer and all other indications.
Independence Blue Cross reissued policy 09.00.10z on 06/11/2025 as part of its annual review process. The policy maintains existing coverage for brachytherapy and accelerated whole breast irradiation (AWBI) with no substantive changes to medical necessity criteria, covered procedures, or billing codes. However, the policy now explicitly applies only to members with Independence Administrators as claims administrator and groups NOT enrolled in UM vendor programs; groups with UM vendor enrollment are excluded upon renewal.
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