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Coverage criteria policies

Electric tumor treatment fields (ETTF) to treat glioblastoma (Optune™)-Minnesota Health Care Programs

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 applicable for electric tumor treatment fields to treat glioblastoma (E0766)

Coverage

Electric tumor treatment fields (ETTF) to treat glioblastoma (E0766) are not covered per Minnesota Health Care Program.

Indications that are covered

None

Indications that are not covered

Electrical stimulation devices used for cancer treatment are considered investigative, not the standard of care and not an effective use of Medicaid dollars.

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

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. Minnesota Health Care Programs (MHCP) Provider Manual: Electrical Stimulation Devices
  2. Department of Human Services – Medical Supply Coverage Guide

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Policy activity

  • 11/08/2017 - Date of origin
  • 11/09/2017 - Effective date

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