Description

Electrical fields, known as "tumor treatment fields" (TTF), are created by low-intensity, alternating intermediate frequency (100-200 kilohertz [kHz]) electric currents delivered to the malignant tumor site by insulated electrodes placed on skin surface of the tumor site. As a result of the unique shape and electrical characteristics of dividing tumor cells, TTF exposure may damage the dividing cells through anti-microtubule mechanisms and could stop tumor growth while sparing normal tissue.

Criteria

TTF may be considered medically necessary when ALL of the following indications are met:

• When it is used as an alternative to standard medical therapy, as a monotherapy; and
• For treatment of adult individuals (22 years of age or older); and
• With histologically-confirmed glioblastoma multiforme; and
• Following histologically- or radiologically-confirmed recurrence in the Supratentorial region of the brain; and
• After receiving chemotherapy; and
• After surgical and radiation options have been exhausted.

OR

TTF may be considered medically necessary when ALL of the following indications are met:

• It is used as an adjunct to standard maintenance therapy; and
• For treatment for adult individuals (22 years of age or older); and
• With histologically-confirmed glioblastoma multiforme; and
• When it is used with temozolomide; and
• With newly diagnosed, supratentorial glioblastoma, and
• Following maximal debulking surgery; and
• Completion of radiation therapy; and
• Together with concomitant standard of care chemotherapy.

TTF is considered experimental/investigational when above criteria are not met or for any other indications, and therefore, not covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes A4555 and E0766