Laser Interstitial Thermal Therapy

Policy ID: S-277-001

Section: Surgery

Effective Date: March 06, 2023

Revision Effective Date: March 04, 2024

Last Reviewed: January 16, 2024

Applies To: Commercial and Medicaid Expansion

Description

Laser interstitial thermal therapy (LITT) involves the introduction of a laser fiber probe to deliver thermal energy for the targeted ablation of diseased tissue. The goal of therapy is selective thermal injury through the maintenance of a sharp thermal border, as monitored via the parallel use of real-time magnetic resonance (MR) thermography and controlled with the use of actively cooled applicators. In neurological applications, LITT involves the creation of a transcranial burr hole for the placement of the laser probe at the target brain tissue. Probe position, ablation time, and intensity are controlled under MRI guidance. LITT has been proposed as a less invasive treatment option for patients with neurological conditions compared to surgery. Two LITT systems, Visualase and NeuroBlate, have received marketing clearance from the FDA.

Criteria

LITT may be considered medically necessary for the treatment of refractory epilepsy when ALL the following criteria are met:

Documented failure to respond to, intolerance of, or contraindication to at least two (2) antiepileptic medications (i.e., medically refractory epilepsy); and
Individual has well-defined epileptogenic foci or critical pathways of seizure propagation accessible by LITT; and
Individual does not have MRI contraindications.

LITT for the treatment of refractory epilepsy not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

61736

61737

LITT may be considered medically necessary for the treatment of newly diagnosed glioblastoma multiforme (GBM), recurrent GBM, and primary or secondary brain metastases when ALL the following criteria is met:

Individual is not a suitable candidate for craniotomy; and
Individual does not have MRI contraindications.

LITT for the treatment of newly diagnosed GBM, recurrent GBM, and primary or secondary brain metastases not meeting the criteria as indicated in this policy is considered not medically necessary.

LITT may be considered medically necessary for the treatment of symptomatic radiation necrosis in the brain when ALL the following criteria is met:

Individual is not a suitable candidate for craniotomy; and
Individual does not have MRI contraindications.

LITT for the treatment of symptomatic radiation necrosis in the brain not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

61736

61737

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes 61736 and 61737

C70.0

C71.0

C71.1

C71.2

C71.3

C71.4

C71.5

C71.6

C71.7

C71.8

C71.9

C79.31

G40.011

G40.019

G40.111

G40.119

G40.211

G40.219

G40.311

G40.319

Y84.2

Professional Statements and Societal Positions Guidelines

American Association of Neurological Surgeons and Congress of Neurological Surgeons 2021

In September 2021, the American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons (CNS) Joint Section on Tumors issued a position statement regarding the use of LITT for brain tumors and radiation necrosis. The statement concludes that 'LITT is an appealing option because it offers a method of minimally invasive, targeted thermal ablation of a lesion with minimal damage to healthy tissue. There is a growing body of evidence to demonstrate that LITT is an effective and well tolerated cytoreductive option for treatment of [newly diagnosed glioblastoma multiforme (GBM), recurrent GBM, and primary or recurrent brain metastases.] Intracranial LITT is also an effective option for addressing radiation necrosis with an overall reduction in steroid dependence for these individuals. Especially in instances where the therapeutic window is narrowed such that craniotomy is not a viable option, LITT can play an important role in treatment for glioma or metastatic brain cancer.'

American Society for Stereotactic and Functional Neurosurgery 2021

In September 2021, the American Society for Stereotactic and Functional Neurosurgery (ASSFN) issued a position statement on the use of LITT in drug-resistant epilepsy. The statement recommends consideration of MR-guided LITT (MRgLITT) as a treatment option when all of the following criteria are met:

'Failure to respond to, or intolerance of, at least two (2) appropriately chosen medications at appropriate doses for disabling, localization-related epilepsy AND

Well-defined epileptogenic foci or critical pathways of seizure propagation accessible by MRgLITT.'

National Comprehensive Cancer Network 2021

The National Comprehensive Cancer Network (NCCN) clinical practice guidelines for central nervous system cancers (v.2.2021) states that MRI-guided laser interstitial thermal therapy 'may be considered for individuals who are not surgical candidates (craniotomy or resection). Potential indications include relapsed brain metastases and radiation necrosis.' (Category 2B)

ND Committee Review

Internal Medical Policy Committee 1-26-2023 New Policy - Effective March 06, 2023

Internal Medical Policy Committee 1-16-2024 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.

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