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Coverage criteria policies

Electric tumor treatment fields (ETTF) to treat glioblastoma (Optune)™

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is not required for electric tumor treatment field therapy to treat glioblastoma.

Coverage

Electric tumor treatment field (ETTF) therapy is generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

Electric tumor treatment fields (ETTF) therapy is covered as follows:

  1. For patients with glioblastoma (GBM) that recurs or progresses after initial treatment; or
  2. As a treatment for adult patients (22 years of age or older) with histologically-confirmed glioblastoma multiforme (GBM) in combination with temozolomide; or
  3. For the treatment of adult patients with newly diagnosed, supratentorial glioblastoma following maximal debulking surgery, and completion of radiation therapy together with concomitant standard of care chemotherapy; or
  4. For the treatment of recurrent GBM following histologically-or radiologically-confirmed recurrence in the supratentorial region of the brain after receiving chemotherapy. The device is intended to be used as a monotherapy, and is intended as an alternative to standard medical therapy for GBM after surgical and radiation options have been exhausted.

Indications that are not covered

Electric tumor treatment fields (ETTF) is not covered for any additional indications.

Definitions

Tumor treating fields (TTFs) therapy uses alternating electric fields to inhibit cell proliferation and lead to programmed cell death. TTF therapy targets dividing cells to stop tumor growth while sparing normal tissue. The Optune™ TTF system is intended to treat patients with glioblastoma by using transducer arrays placed on the patient’s scalp according to the tumor’s location. Patients use the device on an outpatient basis for at least 18 hours per day for 4 weeks to several months. Intended benefits include stabilizing the disease, having fewer treatment-related adverse events, and improving quality of life.

If available, codes for a procedure, device or diagnosis are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all inclusive.

Codes

Description

E0766

Electrical stimulation device used for cancer treatment, includes all accessories, any type

A4555

Electrode/transducer for use with electrical stimulation device used for cancer treatment, replacement only

CPT Copyright American Medical Association. All rights reserved.  CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References:

  1. Batchelor, T. Initial postoperative therapy for glioblastoma and anaplastic astrocytoma. In: UpToDate, Loeffler, J. S., & Wen, P. Y. (Eds), UpToDate, Waltham, MA. (Accessed on August 28, 2018.)
  2. Batchelor, T. Management of recurrent high-grade gliomas. In: UpToDate, Loeffler, J. S., & Wen, P. Y. (Eds), UpToDate, Waltham, MA. (Accessed on August 28, 2018.)
  3. ECRI Institute. (2016). Tumor Treating Fields Therapy (Optune) for Recurrent Glioblastoma. Plymouth Meeting, PA: ECRI Institute.
  4. Hayes, Inc. Hayes Medical Technology Directory Report. Novocure (Tumor Treating Fields. Lansdale, PA: Hayes, Inc.; March, 2016. Reviewed February, 2018.
  5. National Comprehensive Cancer Network. Guidelines for Central Nervous System Cancer V.1.2016 –Teleconference on 02/05/2016. Accessed August 28, 2018 from nccn.org.
  6. Stupp, R., Wong, E. T., Kanner, A. A., Steinberg, D., Engelhard, H., Heidecke, V., … Gutin, P. H. (2012). NovoTTF-100A versus physician's choice chemotherapy in recurrent glioblastoma: A randomised phase III trial of a novel treatment modality. European Journal of Cancer, 48(14), 2192-202. doi: 10.1016/j.ejca.2012.04.011.
  7. Stupp, R., Taillibert, S., Kanner, A. A., Kesari, S., Steinberg, D. M., Toms, S. A., … Ram, Z. (2015). Maintenance therapy with tumor-treating fields plus temozolomide vs temozolomide alone for glioblastoma: A randomized clinical trial. JAMA, 314(23), 2535-2543. doi:10.1001/jama.2015.16669
  8. Stupp, R., Taillibert, S., Kanner, A., Read, W., Steinberg, D. M., Lhermitte, B., … Ram, Z. (2017). Effect of tumor-treating fields plus maintenance temozolomide vs maintenance temozolomide alone on survival in patients with glioblastoma: A randomized clinical trial. JAMA, 318(23), 2306-16. doi:10.1001/jama.2017.18718
  9. U.S. Food and Drug Administration, Center for Devices and Radiological Health (CDRH). Optune P100034/S013 approval letter, dated October 5, 2015. Retrieved September 14, 2018, from https://www.accessdata.fda.gov/cdrh_docs/pdf10/P100034S013A.pdf.

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Policy activity

  • 08/21/2013 - Date of origin
  • 07/01/2018 - Effective date
Review date
  • 07/2018
Revision date
  • 04/12/2016

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