MED.00150 Hepzato Kit™ (melphalan hepatic delivery system)

This policy addresses the Hepzato Kit (percutaneous hepatic perfusion with high‑dose melphalan) for liver-dominant metastatic uveal melanoma. Coverage is medically necessary for adults (18+ years) weighing at least 35 kg who have unresectable hepatic metastases confirmed by CT/MRI, liver involvement of 50% or less, and any extrahepatic disease limited to bone, lymph nodes, subcutaneous tissues, or lung that is amenable to resection or radiation. It is investigational and not medically necessary when these criteria are not met or for any other indications.

"Liver-directed administration of high-dose melphalan (Hepzato Kit) is consideredmedically necessarywhenallof the following criteria are met:"

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