E0767, Intrabuccal, systemic delivery of amplitude-modulated, radiofrequency
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Documentation Required
- For continuation beyond initial 3 months: an MRI scan performed within ≤ 2 months prior to the request showing no evidence of disease progression.
- Histologic confirmation of newly diagnosed GBM (for ndGBM indication).
- Radiologic confirmation of recurrence (for rGBM indication).
- For ndGBM: documentation that debulking surgery has been completed (physician notes including history of all relevant surgeries).
Key Coverage Criteria
- Newly diagnosed, histologically confirmed supratentorial glioblastoma (ndGBM) — use of FDA‑approved electric tumor treatment field (TTF) devices when ALL of the following are met: debulking surgery has been completed; radiation therapy has been completed; the individual is receiving temozolomide (TMZ) as the only cancer drug; Karnofsky Performance Status (KPS) ≥ 60 or ECOG Performance Status ≤ 2; individual has been counseled that the electric TTF device must be worn at least 18 hours daily. [...]
- Radiologically confirmed recurrence of glioblastoma (rGBM) in the supratentorial region — use of FDA‑approved electric TTF devices after initial chemotherapy when ALL of the following are met: the device is used as the only treatment; KPS ≥ 60 or ECOG Performance Status ≤ 2; individual has been counseled that the electric TTF device must be worn at least 18 hours daily. When criteria met, an initial 3 months of electric TTF therapy will be approved.
- Indication: For newly diagnosed histologically confirmed supratentorial GBM, use FDA-approved TTFields device per FDA indications, with: debulking completed, radiation completed, TMZ as the only cancer drug, KPS ≥60 or ECOG ≤2, and device worn ≥18 hours daily; initial 3 months approved.
6 Active Policies
UHC-POL-electric-tumor-treatment-field-therapy, Electric Tumor Treatment Field Therapy
REGENCE-DME96, Amplitude-Modulated Radiofrequency Electromagnetic Fields (AM RF-EMF) for Cancer Treatment
UMR-POL-UMR-electric-tumor-treatment-field-therapy, Electric Tumor Treatment Field Therapy
SUREST-POL-SUREST-electric-tumor-treatment-field-therapy, Electric Tumor Treatment Field Therapy
Related Codes
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