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Intraperitoneal Chemotherapy

Section: Injections
Effective Date: June 30, 2018
Revised Date: November 11, 2019
Last Reviewed: November 14, 2019

Description

Early intraperitoneal chemotherapy (EIPC) 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

Early Intraperitoneal chemotherapy (EPIC) 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 optimally debulked (residual tumor less than or equal to 1.0 cm in diameter) epithelial ovarian cancer; or
  • Optimally debulked pseudomyxoma peritonei or mesothelioma of the peritoneum; or
  • Optimally debulked peritoneal surface malignancies from tumors of gastrointestinal origin (excluding pancreas).

EPIC or HIPEC reported for any other indication is considered experimental/investigational, and therefore, non-covered. Scientific evidence does not support the use of EPIC and HIPEC for any other indications.

Procedure Codes

77605 77620 96446 96549

Diagnosis Codes

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 C56.9 C78.6

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