Intraperitoneal Chemotherapy

Policy ID: I-91-020

Section: Injections

Effective Date: July 01, 2018

Revised Date: December 16, 2022

Revision Effective Date: January 02, 2023

Last Reviewed: March 23, 2023

Applies To: Commercial and Medicaid Expansion

Description

Intraperitoneal chemotherapy is administered directly into the abdominal cavity. The first dose of chemolytic agents may be infused post-surgery with subsequent doses given over a course of several days.

Hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC), also referred to as intraperitoneal hyperthermic chemotherapy (IPHC), is instilled during surgery, via an open or closed abdominal approach. The heated chemolytic agent is infused into the peritoneal cavity, raising the temperature of the tissues within the cavity to 106–108 °Fahrenheit (F). Because various tissue thicknesses are present within the peritoneal cavity, there is a concern that the entire cavity may not be receiving an even exposure to the medication. Extensive surgical debulking is imperative.

Criteria

Intraperitoneal chemotherapy or Hyperthermic Intraoperative Intraperitoneal chemotherapy (HIPEC) may be considered medically necessary when used in combination with cytoreductive surgery for ANY ONE of the following indications:

Stage III epithelial ovarian, fallopian tube or primary peritoneal cancer at the time of interval debulking surgery; or
Optimally debulked (residual tumor less than or equal to 1.0cm in diameter) pseudomyxoma peritonei or mesothelioma of the peritoneum; or
Optimally debulked peritoneal surface malignancies from tumors of gastrointestinal or colorectal origin (excluding pancreas) without distant metastases.

Intrapertinoneal chemotherapy or HIPEC not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer -reviewed literature.

Procedure Codes

77605

77620

96446

96549

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes 77605, 77620 and 96446.

C16.0

C16.1

C16.2

C16.3

C16.4

C16.5

C16.6

C16.8

C16.9

C17.0

C17.1

C17.2

C17.3

C17.8

C17.9

C18.0

C18.1

C18.2

C18.3

C18.4

C18.5

C18.6

C18.7

C18.8

C18.9

C19

C20

C21.0

C21.1

C21.2

C21.8

C22.0

C22.1

C22.2

C22.3

C22.4

C22.7

C22.8

C22.9

C23

C24.0

C24.1

C24.8

C24.9

C26.0

C26.1

C26.9

C45.1

C48.0

C48.1

C48.2

C48.8

C56.1

C56.2

C56.3

C56.9

C57.00

C57.01

C57.02

C57.10

C57.11

C57.12

C57.20

C57.22

C57.3

C57.4

C57.7

C57.8

C57.9

C78.6

C79.60

C79.61

C79.62

C79.63

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-14-2019 No HMK update since 2016

Internal Medical Policy Committee 11-19-2020 Annual Review

Internal Medical Policy Committee 11-23-2021 Annual Review-no changes in criteria

Internal Medical Policy Committee 11-29-2022 Revision with coding update-Effective January 02, 2023

Added diagnosis codes C57.00; C57.01; C57.02; C57.10; C57.11; C7.12; C57.20; C57.22; C57.3; C57.4; C57.7; C57.8; C57.9; C79.60; C79.61; and C79.62.

Internal Medical Policy Committee 3-23-2023 Annual Review-no changes in criteria

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: I-91-019