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.