Medical_Policy_Bulletin

Highmark Commercial Medical Policy - Pennsylvania

Medical Policy:	S-109-012
Topic:	Transcatheter Arterial Chemoembolization
Section:	Surgery
Effective Date:	November 27, 2017
Issue Date:	August 6, 2018
Last Reviewed:	July 2018

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.

Policy Position Coverage is subject to the specific terms of the member’s benefit plan.

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 individuals with metastatic neuroendocrine tumors whose symptoms persist despite systemic therapy and who are not candidates for surgical resection; or
Treatment of liver metastasis in individuals with liver-dominant metastatic uveal melanoma; or
As a bridge to transplant in individuals with hepatocellular cancer where the intent is to prevent further tumor growth and to maintain an individual’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.

TACE 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.

Procedure Codes

37243

Place of Service: Inpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

The policy position applies to all commercial lines of business

Denial Statements

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Links

Link to Provider Resource Center for the Medical Policy Update

01/2016, Criteria Revised for Transcatheter Arterial Chemoembolization

Link to Diagnosis Codes

Link to References

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:

Qualified sign language interpreters

Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:

Qualified interpreters

Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.