Medical Policy
Effective Date:09/18/1995 Title:Hyperthermia, Oncology Applications
Revision Date:10/01/2015 Document:BI210:00
CPT Code(s):77600, 77605, 77610, 77615, 77620
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Regional hyperthermia (heat treatment) may be used with either radiation or medication treatment of some cancers.

2)    When medically appropriate, such treatment is covered.
Medical Statement

1)    Local hyperthermia is considered an appropriate cancer therapy under specific circumstances.  The following types of hyperthermia are eligible for coverage:

a)    Sequential radiation-local/regional external hyperthermia may be used for:

i)     superficial (not greater than 8 cm) recurrent melanoma

ii)    chest wall recurrence of breast cancer

iii)   extensive local extension or cervical lymph node metastases from head and neck cancer.

b)    Regional hyperthermic mephalan perfusion in patients with Stage II and IIIA extremity melanoma.

 

Codes Used In This BI:

77600 Hyperthermia treatment
77605 Hyperthermia treatment
77610 Hyperthermia treatment
77615 Hyperthermia treatment
77620 Hyperthermia treatment
 
Limits

1)    Due to lack of clinically controlled studies proving effectiveness the following conditions are not eligible for coverage:

a)    Hyperthermic mephalan perfusion in Stage I, IIIB, and IIAB extremity melanoma, as well as hyperthermia in conjunction with any other chemotherapy

b)    Deep hyperthermia alone or in combination with radiation therapy

c)    Interstitial (77610, 77615)hyperthermia

d)    Intracavitary (77620) hyperthermia

e)    Whole body hyperthermia   HAYES D

f)     Regional hyperthermia for indications other than those listed above

g)    Intraperitoneal hyperthermic chemotherapy for peritoneal surface malignancy (peritoneal carcinomatosis or pseudomyxoma peritonei). HAYES C
Reference

1)    Hayes Manual, HYPE0201.16, Hyperthermia Treatment for Cancer, Whole Body, November 28, 1997

2)    Hayes Manual, Intraperitoneal Hyperthermic Chemotherapy for Abdominopelvic Cancers, June 10, 2006

3)    National Institute for Clinical Excellence (NICE). Complete cytoreduction and heated intraoperative intraperitoneal chemotherapy (Sugarbaker technique) for peritoneal carcinomatosis. Interventional Procedure Guidance 116. London, UK: NICE; March 2005. Available at: http://www.nice.org.uk/page.aspx?o=248131

4)    Arkansas BlueCross BlueShield Coverage Policy Manual, Hyperthermia at: http://www.arkansasbluecross.com/members/report.aspx?policyNumber=1998034
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.