Description

Transcatheter arterial chemoembolization (TACE) is a treatment modality for unresectable hepatic malignancies. Similar to hepatic arterial infusions, this technique exploits the selective blood supply to the neoplastic lesions provided by the hepatic artery. Chemoembolization is performed by introducing a vascular occlusion agent combined with cytotoxic drugs into the hepatic artery, which results in dual ischemic and cytotoxic insult to the tumor.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person’s unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Transcatheter arterial chemoembolization (TACE) may be considered medically necessary for ANY of the following indications:

• Treatment of hepatocellular cancer or cholangiocarcinoma, that is unresectable but confined to the liver and not associated with portal vein thrombosis; or
• Treatment of liver metastasis in symptomatic patients with metastatic neuroendocrine tumors whose symptoms persist despite systemic therapy and who are not candidates for surgical resection; or
• Treatment of liver metastasis in patients with liver-dominant metastatic uveal melanoma; or
• As a bridge to transplant in patients with hepatocellular cancer where the intent is to prevent further tumor growth and to maintain a patient's candidacy for liver transplant and ALL of the following:
  • Single tumor less than 5 cm or no more than three (3) tumors less than 3 cm in size; and
  • Absence of extra hepatic disease or vascular invasion; and
  • Child-Pugh score of either A or B.

Transcatheter arterial chemoembolization is considered experimental/investigational when the above criteria are not met, including but not limited to, palliative treatment of either primary or secondary malignant disease of the liver that is not associated with a specific liver-related symptom. There is a lack of evidence based literature to confirm the efficacy and safety for any other indication.

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Diagnosis Codes