A4555 — Electrode/transducer for use with electrical stimulation device used for cancer treatment, replacement only
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Histologic confirmation of WHO grade IV astrocytoma (GBM) in the medical record is required.
- Medical record documentation of initial treatments: maximal debulking surgery (when feasible), chemotherapy, and radiotherapy is required.
- Documentation of no progression per RANO criteria must be in the medical record prior to initiating TTFT.
- Karnofsky Performance Score (KPS) documented as ≥70 in the medical record is required.
Key Coverage Criteria
- Tumor treating field therapy (HCPCS E0766) is covered for newly diagnosed, histologically confirmed WHO grade IV astrocytoma (glioblastoma multiforme) that is supratentorial.
- Beneficiary must have received initial treatment consisting of maximal debulking surgery when feasible, followed by chemotherapy and radiotherapy prior to initiation of TTFT.
- TTFT must be initiated within 7 weeks from the last dose of concomitant chemotherapy or radiotherapy, whichever is later.
- Beneficiary must have no evidence of progression by Response Assessment in Neuro‑Oncology (RANO) criteria at initiation.
- Beneficiary must have a Karnofsky Performance Score (KPS) of at least 70 documented prior to coverage.
- Beneficiary must plan to use TTFT for an average of 18 hours per day.
7 Active Policies
L34823 — Tumor Treatment Field Therapy (TTFT)
J19
UHC-POL-electric-tumor-treatment-field-therapy — Electric Tumor Treatment Field Therapy
ANTHEM-CG-DME-44 — CG-DME-44 Electric Tumor Treatment Field (TTF)
AMBETTER-CP.MP.145 — Electric Tumor Treating Fields (Optune)
UMR-POL-UMR-electric-tumor-treatment-field-therapy
Related Codes
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