Durable Medical Equipment (DME) - Tumor Treating Fields (Alternating Electric Field Therapy) Form

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Durable Medical Equipment (DME): Tumor Treating Fields (Alternating Electric Field Therapy) Medical Guideline

Service: DME: Tumor Treating Fields (Alternating Electric Field Therapy)

PUM 250-0024-1812

Medical Guideline Committee Approval Q1 2026 Effective Date 05/01/2026

Description: Tumor Treating Fields (TTFs), also known as Alternating Electric Field Therapy, Novo TTF Therapy, and Optune®, are low intensity alternating electric fields used as treatment for glioblastoma multiforme (GBM). TTFs are used to disrupt the division of tumor cells and inhibit tumor growth.

Note: This medical guideline addresses the tumor treating fields device only and does not address any chemotherapy drugs. For information related to drugs, see the Drug Prior Authorization List at: https://wpshealth.com/resources/files/drugpreauth.pdf.

Indications of Coverage:

I. Tumor treating fields therapy (alternating electric field therapy) is considered medically necessary for newly diagnosed glioblastoma multiforme (GBM) only when ALL of the following criteria are met:

1. The member has histologically confirmed (World Health Organization [WHO], grade IV astrocytoma), newly diagnosed, supratentorial GBM.
2. The member has received initial treatment with maximal debulking surgery (when feasible), followed by chemotherapy and radiotherapy.
3. Tumor treatment field therapy is initiated within 7 weeks from the last dose of concomitant chemotherapy or radiotherapy, whichever is later.
4. The member has no evidence of progression by Response Assessment in Neuro-Oncology (RANO) criteria.
5. The member has a Karnofsky Performance Score (KPS) of at least 70;

6. The member will use TTFT for an average of 18 hours per day.

   If Indications of Coverage are met, the tumor treating fields device may be approved for 3 months. Continued use will require review by the Health Plan’s Medical Director every 3 months.

   Continued coverage for newly diagnosed GBM beyond the first three (3) months of therapy: requires that no sooner than the 60th day but no later than the 91st day after initiating therapy, the treating practitioner must conduct a clinical re-evaluation and document that the member is continuing to use and is benefiting from TTFT.

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Documentation of clinical benefit is demonstrated by:

1. In-person clinical re-evaluation by the treating practitioner; AND

2. Objective evidence of adherence to therapy, reviewed by the treating practitioner.

   Adherence to therapy is defined as the use of TTFT for an average of 18 hours per day (excluding days the treating practitioner has documented a medical need to limit or interrupt treatment).

   If the practitioner re-evaluation does not occur until after the 91st day but the evaluation demonstrates that the member is benefiting from TTFT as defined in criteria 1 and 2 above, continued coverage of TTFT may commence with the date of that re-evaluation.

   Recurrent GBM: Tumor treatment field therapy will be considered not medically necessary for the treatment of recurrent GBM.

   Limitations of Coverage:

   Benefit Limitations: Please note that in listing services or examples, when we say, “this includes,” it is not our intent to limit the description to that specific list. When we do intend to limit a list of services or examples, we state specifically that the list “is limited to.” A. Review contracts and endorsements for exclusions and prior authorization or benefit requirements.

   B. If used for a condition/diagnosis other than is listed in the Indications of Coverage, it will be considered experimental, investigational, and unproven to affect health outcomes.

   C. If used for a condition/diagnosis that is listed in the Indications of Coverage; but the criteria are not met, it will be considered not medically necessary.

   D. Use of tumor treating fields for any indication other than newly diagnosed GBM will be considered not medically necessary.

   E. Continued use will require review by the Health Plan’s Medical Director every 3 months.

   Documentation Required:

   • Standard Written Order (SWO) prescribed by a qualified healthcare provider concerning the member’s diagnosis. • Medical record information (including continued need/use if applicable) and medical necessity. Reports confirming diagnosis, surgical, chemotherapy, radiation, and other relevant treatment history. • Current coding for the item/service that meets all the coding guidelines.

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• Continued use requires review by the Health Plan’s Medical Director every 3 months.
Provider must submit updated clinical documentation relevant to disease status along with request for authorization extension every 3 months.

Disclaimer: This guideline is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage, and some plans may or may not provide coverage for all services listed in this guideline. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical guidelines in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information.
Medical guidelines are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. This medical guideline and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, email medical.policies@wpsic.com. Coverage of all services is subject to medical necessity and services deemed experimental, investigational, and/or unproven and therefore not considered medically necessary under the terms of the clinical guidelines and will not be covered. State mandates, laws or benchmark supersede this medical guideline.

Tumor treating fields are considered medically necessary only when indicated per the most current medical references and specialty society guidelines, such as MCG, NCCN, etc.

Guideline Review History:

Implemented 10/01/19, 07/01/21, 07/01/22, 07/01/23, 07/01/24, 01/01/26, 05/01/26 Medical Guideline Committee Approval 05/31/19, 6/18/20, 06/24/21, 06/23/22, 06/29/23, 06/27/24, 03/27/25, Q1 2026 Reviewed

6/18/20, 06/24/21, 06/23/22, 06/29/23, 06/27/24, 03/27/25, Q1 2026 Developed 05/31/19

Approved by the Medical Director

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Codes: The following codes for treatments and procedures applicable to this document are included below for informational purposes.

Code Description 64999 Unlisted procedure, nervous system (for the use of treatment planning software-novotal)
77299 Unlisted procedure, therapeutic radiology clinical treatment planning
A4555 Electrode/transducer for use with electrical stimulation device used for cancer treatment, replacement only
E0766 Electrical stimulation device used for cancer treatment, includes all accessories, any type
E0767 Intrabuccal, systemic delivery of amplitude-modulated, radiofrequency electromagnetic field device, for cancer treatment, includes all accessories
J8700 Temozolomide, oral, 5 mg
J9328 Injection, Temozolomide, 1 mg