Anthem Blue Cross Connecticut CG-MED-72 Hyperthermia for Cancer Therapy Form

This document addresses hyperthermia for cancer therapy. Hyperthermia is a type of cancer treatment in which body tissue is exposed to high temperatures using external and internal heating devices. Hyperthermia is routinely used with other forms of cancer therapy. Hyperthermia may make cancer cells more sensitive to chemotherapy and radiation therapy or harm other cancer cells radiation cannot damage.

Note: This document does not address hyperthermic intraperitoneal chemotherapy (HIPEC), hyperthermic limb perfusion, radiofrequency ablation to treat tumors outside the liver or locally ablative techniques for treating primary and metastatic liver malignancies.

For information regarding radiofrequency ablation to treat tumors outside the liver or locally ablative techniques for treating primary and metastatic liver malignancies see the following documents:

• CG-SURG-61 Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the Liver
• CG-SURG-78 Locoregional Techniques for Treating Primary and Metastatic Liver Malignancies

Clinical Indications

Medically Necessary:

Local hyperthermia, using either external or interstitial modalities, in combination with radiation therapy is considered medically necessary for the treatment of individuals with primary or metastatic cutaneous or subcutaneous superficial tumors (for example, superficial recurrent melanoma, chest wall recurrence of breast cancer, and cervical lymph node metastases from head and neck cancer); and

When criteria above are met, local hyperthermia is considered medically necessary when used no more than twice weekly.

Not Medically Necessary:

Local hyperthermia, using either external or interstitial modalities, in conjunction with radiation therapy is considered not medically necessary for all other uses not identified as medically necessary.

Local hyperthermia is considered not medically necessary when given more than two times per week.

Intraluminal/endocavitary hyperthermia is considered not medically necessary in the treatment of malignancies.

Regional deep tissue hyperthermia is considered not medically necessary in the treatment of malignancies.

Whole-body hyperthermia is considered not medically necessary in the treatment of malignancies.

Hyperthermia in conjunction with chemotherapy is considered not medically necessary.