96425
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.17
Facility
$174.02
Non-Facility
$174.02
Documentation Required
- When using SIR-Spheres, documentation of absence of recent capecitabine exposure (no capecitabine within past 2 months) and no planned capecitabine after treatment, or other documented contraindicated concurrent/planned therapies.
- No documentation requirements are specified in this document.
- For PEI: documentation of number and size of HCC foci (policy notes PEI effective for fewer than 4 small foci < 5 cm) and absence of coagulopathy or ascites.
- For intra-hepatic microspheres (TARE): diagnostic work-up prior to use includes a hepatic angiogram to assess vasculature and delivery route, and a Technetium-99 macroaggregated albumin (Tc-99 MAA) study to evaluate hepatic flow to the gastrointestinal tract and/or pulmonary shunting; these studies are medically necessary and eligible for coverage.
Key Coverage Criteria
- Chemoembolization (CE/TACE) is medically necessary for liver-only metastasis from uveal (ocular) melanoma.
- Chemoembolization (CE/TACE) is medically necessary as pre-operative hepatic artery chemoembolization followed by orthotopic liver transplantation for HCC (i.e., bridge to transplant).
- Percutaneous Ethanol Injection (PEI) is medically necessary for the treatment of hepatocellular cancers (HCC) without extra-hepatic spread.
- Chemoembolization (CE/TACE) is medically necessary for treatment of neuroendocrine cancers (i.e., carcinoid tumors and pancreatic endocrine tumors) involving the liver (for carcinoid tumors CE is considered medically necessary only in persons who have failed systemic therapy with octreotide to control carcinoid syndrome, e.g., debilitating flushing, wheezing and diarrhea).
- Chemoembolization (CE/TACE) is medically necessary for unresectable, primary hepatocellular carcinoma (HCC).
- Intra-hepatic chemotherapy (hepatic arterial infusion; HAI) is medically necessary for members with liver metastases from colorectal cancer.
1 Active Policy
AETNA-CPB-0268 — Liver and Other Neoplasms - Treatment Approaches
Related Codes
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