948 Form

1

Medical Policy
Laser Interstitial Thermal Therapy
Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 948 BCBSA Reference Number: 7.01.170 (For Plan internal use only) NCD/LCD: N/A Related Policies
Responsive Neurostimulation for the Treatment of Refractory Partial Epilepsy #716 Vagus Nerve Stimulation #474 Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity
Medicare HMO BlueSM and Medicare PPO BlueSM Members

Laser interstitial thermal therapy (LITT) is considered INVESTIGATIONAL for all neurological indications, including but not limited to individuals with primary or metastatic brain tumors, radiation necrosis, and drug-resistant epilepsy.

Laser interstitial thermal therapy (LITT) is considered INVESTIGATIONAL for the treatment of psychiatric disorders, including but not limited to depression, treatment resistant depression or obsessive-compulsive disorder.

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) This is not a covered service. Commercial PPO and Indemnity This is not a covered service. Medicare HMO BlueSM This is not a covered service. Medicare PPO BlueSM This is not a covered service.

2

CPT Codes / HCPCS Codes / ICD Codes
Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following codes are included below for informational purposes only; this is not an all-inclusive list.

The following CPT codes are considered investigational for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue: CPT Codes CPT codes:

Code Description 61736 Laser interstitial thermal therapy (LITT) of lesion, intracranial, including burr hole(s), with magnetic resonance imaging guidance, when performed; single trajectory for 1 simple lesion 61737 Laser interstitial thermal therapy (LITT) of lesion, intracranial, including burr hole(s), with magnetic resonance imaging guidance, when performed; multiple trajectories for multiple or complex lesion(s)
Description Laser Interstitial Thermal Therapy Laser interstitial thermal therapy (LITT) involves the introduction of a laser fiber probe to deliver thermal energy for the targeted ablation of diseased tissue. Thermal destruction of tissue is mediated via DNA damage, necrosis, protein denaturation, membrane dissolution, vessel sclerosis, and coagulative necrosis.1, The goal of therapy is selective thermal injury through the maintenance of a sharp thermal border, as monitored via the parallel use of real-time magnetic resonance (MR) thermography and controlled with the use of actively cooled applicators.2, In neurological applications, LITT involves the creation of a transcranial burr hole for the placement of the laser probe at the target brain tissue. Probe position, ablation time, and intensity are controlled under magnetic resonance imaging (MRI) guidance.

The majority of neurological LITT indications described in the literature involve the ablation of primary and metastatic brain tumors, epileptogenic foci, and radiation necrosis in surgically inaccessible or eloquent brain areas.2, LITT may offer a minimally invasive treatment option for patients with a high risk of morbidity with traditional surgical approaches. The most common complications following LITT are transient and permanent weakness, cerebral edema, hemorrhage, seizures, and hyponatremia.3, Delayed neurological deficits due to brain edema are temporary and typically resolve after corticosteroid therapy. Contraindications to MRI are also applicable to the administration of LITT.

Summary
Description Laser interstitial thermal therapy (LITT) involves the introduction of a laser fiber probe to deliver thermal energy for the targeted ablation of diseased tissue. The goal of therapy is selective thermal injury through the maintenance of a sharp thermal border, as monitored via the parallel use of real-time magnetic resonance (MR) thermography and controlled with the use of actively cooled applicators. In neurological applications, LITT involves the creation of a transcranial burr hole for the placement of the laser probe at the target brain tissue. Probe position, ablation time, and intensity are controlled under magnetic resonance imaging (MRI) guidance. LITT has been proposed as a less invasive treatment option for patients with neurological conditions compared to surgery. Two LITT systems, Visualase and NeuroBlate®, have received marketing clearance from the U.S. Food and Drug Administration (FDA).

3

Summary of Evidence For individuals who have primary or metastatic brain tumors who receive magnetic resonance (MR)-guided laser interstitial thermal therapy (LITT), the evidence includes systematic reviews and meta-analyses and several nonrandomized comparative and single-arm studies. Relevant outcomes are overall survival (OS), disease-specific survival, symptoms, change in disease status, functional outcomes, quality of life, and treatment-related morbidity. Overall survival estimates have ranged from 9.0 to 14.4 months in new or recurrent glioblastoma. Among patients with metastatic tumors receiving LITT following prior stereotactic radiosurgery (SRS), OS rates have ranged between 72% to 76% at 6 months and 63% to 65% at 12 months. In a more heterogenous population of patients with primary and metastatic brain tumors who received LITT, 12-month OS rates were slightly lower in patients with brain metastases (56.3%) and high-grade glioma (43.0%) than other analyses. Systematic reviews comparing LITT to open craniotomy with resection or SRS suggest a reduced incidence of adverse events with LITT; however, neurological deficits attributable to LITT-induced thermal damage have been observed despite concurrent magnetic resonance imaging (MRI) guidance. Studies are limited by predominantly retrospective designs, small sample sizes, and population heterogeneity, with study subjects varying by performance status, lesion volume and location, extent of prior therapies, and extent of ablation. Prospective comparative studies in well-defined and -controlled patient populations are lacking. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have symptomatic cranial radiation necrosis who receive MR-guided LITT, the evidence includes meta-analyses, nonrandomized comparative studies, and a single-arm study. Relevant outcomes are OS, disease-specific survival, symptoms, change in disease status, functional outcomes, quality of life, and treatment-related morbidity. Studies have reported improved local control and survival outcomes in patients with radiation necrosis compared to those with brain metastases. One study comparing LITT to bevacizumab suggested that LITT treatment may be more successful among patients before radiation necrosis lesions become symptomatic. One study comparing LITT to craniotomy and one study comparing LITT to medical management did not report significant survival differences between groups. Studies are limited by retrospective designs, small sample sizes, population heterogeneity, and unclear relevance, as symptomatic status and steroid-related morbidity were not consistently reported. Prospective comparative studies in well-defined and -controlled patient populations are lacking. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have drug-resistant epilepsy who receive MR-guided LITT, the evidence includes systematic reviews and meta-analyses, nonrandomized comparative studies, and single-arm studies. Relevant outcomes are disease-specific survival, symptoms, change in disease status, functional outcomes, quality of life, and treatment-related morbidity. Meta-analyses have reported seizure freedom rates ranging from 50% to 61% but are limited by heterogeneous study populations and follow-up durations. Studies comparing LITT to open resection have reported comparable outcomes in patients with pediatric insular epilepsy and adult temporal lobe epilepsy (TLE). In one meta-analysis comparing LITT to radiofrequency ablation (RFA) and conventional surgery, superior outcomes were noted with conventional surgery among patients with TLE. A subsequent meta-analysis concluded that while there is no evidence to suggest that LITT is less effective than open surgical resection in the short term, long-term data are lacking. Total quality of life scores reported in the ongoing LAANTERN registry increased by 72.4%, but this change was not considered statistically significant. Prospective comparative studies in well-defined and -controlled patient populations are required to assess a net health outcome and to identify patients most likely to benefit from LITT. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

While LITT has been evaluated mostly for neurological conditions, there have been some studies evaluating improved patient outcomes for individuals with psychiatric conditions such as depression, treatment resistant depression and obsessive-compulsive disorder. One small retrospective review and one small nonrandomized study evaluated the safety and effectiveness of LITT in reducing symptoms of mood disorder and obsessive-compulsive disorder. Larger randomized clinical trials and comparative data are needed. The evidence is insufficient to determine that this technology results in an improvement in the net health outcomes.

4

Policy History Date Action 2/2026 Annual policy review. Policy updated with literature review through October 22, 2025; references added. Policy statements unchanged. 9/2025 Investigational statement clarified. 9/1/2025.
2/2025 Annual policy review. Policy updated with literature review through October 14, 2024; references added. Policy statements unchanged.
1/2024 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 2/2023 Annual policy review. Minor editorial refinements to policy statement; intent unchanged. 5/2022 New medical policy describing investigational indications for laser interstitial thermal therapy for all neurological indications, including but not limited to primary and metastatic brain tumors, radiation necrosis, and drug-resistant epilepsy. Effective 5/1/2022. Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines References

1. Lagman C, Chung LK, Pelargos PE, et al. Laser neurosurgery: A systematic analysis of magnetic resonance-guided laser interstitial thermal therapies. J Clin Neurosci. Feb 2017; 36: 20-26. PMID 27838155
2. Medvid R, Ruiz A, Komotar RJ, et al. Current Applications of MRI-Guided Laser Interstitial Thermal Therapy in the Treatment of Brain Neoplasms and Epilepsy: A Radiologic and Neurosurgical Overview. AJNR Am J Neuroradiol. Nov 2015; 36(11): 1998-2006. PMID 26113069
3. Holste KG, Orringer DA. Laser interstitial thermal therapy. Neurooncol Adv. 2020; 2(1): vdz035. PMID 32793888
4. Pandey A, Chandla A, Mekonnen M, et al. Safety and Efficacy of Laser Interstitial Thermal Therapy as Upfront Therapy in Primary Glioblastoma and IDH-Mutant Astrocytoma: A Meta-Analysis. Cancers (Basel). Jun 03 2024; 16(11). PMID 38893250
5. Zhao X, Li R, Guo Y, et al. Laser interstitial thermal therapy for recurrent glioblastomas: a systematic review and meta-analysis. Neurosurg Rev. Apr 16 2024; 47(1): 159. PMID 38625588
6. Alkazemi M, Lo YT, Hussein H, et al. Laser Interstitial Thermal Therapy for the Treatment of Primary and Metastatic Brain Tumors: A Systematic Review and Meta-Analysis. World Neurosurg. Mar 2023; 171: e654-e671. PMID 36549438
7. Chen C, Guo Y, Chen Y, et al. The efficacy of laser interstitial thermal therapy for brain metastases with in-field recurrence following SRS: systemic review and meta-analysis. Int J Hyperthermia. 2021; 38(1): 273-281. PMID 33612043
8. de Franca SA, Tavares WM, Salinet ASM, et al. Laser interstitial thermal therapy as an adjunct therapy in brain tumors: A meta-analysis and comparison with stereotactic radiotherapy. Surg Neurol Int. 2020; 11: 360. PMID 33194293
9. Barnett GH, Voigt JD, Alhuwalia MS. A Systematic Review and Meta-Analysis of Studies Examining the Use of Brain Laser Interstitial Thermal Therapy versus Craniotomy for the Treatment of High- Grade Tumors in or near Areas of Eloquence: An Examination of the Extent of Resection and Major Complication Rates Associated with Each Type of Surgery. Stereotact Funct Neurosurg. 2016; 94(3): 164-73. PMID 27322392
10. Grabowski MM, Srinivasan ES, Vaios EJ, et al. Combination laser interstitial thermal therapy plus stereotactic radiotherapy increases time to progression for biopsy-proven recurrent brain metastases. Neurooncol Adv. 2022; 4(1): vdac086. PMID 35795470

5

11. Fadel HA, Haider S, Pawloski JA, et al. Laser Interstitial Thermal Therapy for First-Line Treatment of Surgically Accessible Recurrent Glioblastoma: Outcomes Compared With a Surgical Cohort. Neurosurgery. Nov 01 2022; 91(5): 701-709. PMID 35986677
12. Mohammadi AM, Sharma M, Beaumont TL, et al. Upfront Magnetic Resonance Imaging-Guided Stereotactic Laser-Ablation in Newly Diagnosed Glioblastoma: A Multicenter Review of Survival Outcomes Compared to a Matched Cohort of Biopsy-Only Patients. Neurosurgery. Dec 01 2019; 85(6): 762-772. PMID 30476325
13. Rennert RC, Khan U, Bartek J, et al. Laser Ablation of Abnormal Neurological Tissue Using Robotic Neuroblate System (LAANTERN): Procedural Safety and Hospitalization. Neurosurgery. Apr 01 2020; 86(4): 538-547. PMID 31076762
14. Kim AH, Tatter S, Rao G, et al. Laser Ablation of Abnormal Neurological Tissue Using Robotic NeuroBlate System (LAANTERN): 12-Month Outcomes and Quality of Life After Brain Tumor Ablation. Neurosurgery. Sep 01 2020; 87(3): E338-E346. PMID 32315434
15. de Groot JF, Kim AH, Prabhu S, et al. Efficacy of laser interstitial thermal therapy (LITT) for newly diagnosed and recurrent IDH wild-type glioblastoma. Neurooncol Adv. 2022; 4(1): vdac040. PMID 35611270
16. Gecici NN, Gurses ME, Kaye B, et al. Comparative analysis of bevacizumab and LITT for treating radiation necrosis in previously radiated CNS neoplasms: a systematic review and meta-analysis. J Neurooncol. May 2024; 168(1): 1-11. PMID 38619777
17. Vellayappan B, Lim-Fat MJ, Kotecha R, et al. A Systematic Review Informing the Management of Symptomatic Brain Radiation Necrosis After Stereotactic Radiosurgery and International Stereotactic Radiosurgery Society Recommendations. Int J Radiat Oncol Biol Phys. Jan 01 2024; 118(1): 14-28. PMID 37482137
18. Palmisciano P, Haider AS, Nwagwu CD, et al. Bevacizumab vs laser interstitial thermal therapy in cerebral radiation necrosis from brain metastases: a systematic review and meta-analysis. J Neurooncol. Aug 2021; 154(1): 13-23. PMID 34218396
19. Sankey EW, Grabowski MM, Srinivasan ES, et al. Time to Steroid Independence After Laser Interstitial Thermal Therapy vs Medical Management for Treatment of Biopsy-Proven Radiation Necrosis Secondary to Stereotactic Radiosurgery for Brain Metastasis. Neurosurgery. Jun 01 2022; 90(6): 684-690. PMID 35311745
20. Sujijantarat N, Hong CS, Owusu KA, et al. Laser interstitial thermal therapy (LITT) vs. bevacizumab for radiation necrosis in previously irradiated brain metastases. J Neurooncol. Jul 2020; 148(3): 641-
21. PMID 32602021
22. Hong CS, Deng D, Vera A, et al. Laser-interstitial thermal therapy compared to craniotomy for treatment of radiation necrosis or recurrent tumor in brain metastases failing radiosurgery. J Neurooncol. Apr 2019; 142(2): 309-317. PMID 30656529
23. Ahluwalia M, Barnett GH, Deng D, et al. Laser ablation after stereotactic radiosurgery: a multicenter prospective study in patients with metastatic brain tumors and radiation necrosis. J Neurosurg. Mar 01 2019; 130(3): 804-811. PMID 29726782
24. Kwan P, Arzimanoglou A, Berg AT, et al. Definition of drug resistant epilepsy: consensus proposal by the ad hoc Task Force of the ILAE Commission on Therapeutic Strategies. Epilepsia. Jun 2010; 51(6): 1069-77. PMID 19889013
25. Wieser HG, Blume WT, Fish D, et al. ILAE Commission Report. Proposal for a new classification of outcome with respect to epileptic seizures following epilepsy surgery. Epilepsia. Feb 2001; 42(2): 282-6. PMID 11240604
26. Ekman F, Bjellvi J, Ljunggren S, et al. Laser interstitial thermal therapy versus open surgery for mesial temporal lobe epilepsy: A systematic review and meta-analysis. World Neurosurg. Sep 25
27. PMID 39332763
28. Hect JL, Harford E, Maroufi SF, et al. Clinical outcomes of MR-guided laser interstitial thermal therapy corpus callosum ablation in drug-resistant epilepsy: a systematic review and meta-analysis. J Neurosurg Pediatr. Jan 01 2024; 33(1): 12-21. PMID 37856385
29. Barot N, Batra K, Zhang J, et al. Surgical outcomes between temporal, extratemporal epilepsies and hypothalamic hamartoma: systematic review and meta-analysis of MRI-guided laser interstitial thermal therapy for drug-resistant epilepsy. J Neurol Neurosurg Psychiatry. Feb 2022; 93(2): 133-
30. PMID 34321344

6

28. Marathe K, Alim-Marvasti A, Dahele K, et al. Resective, Ablative and Radiosurgical Interventions for Drug Resistant Mesial Temporal Lobe Epilepsy: A Systematic Review and Meta-Analysis of Outcomes. Front Neurol. 2021; 12: 777845. PMID 34956057
29. Kohlhase K, Zöllner JP, Tandon N, et al. Comparison of minimally invasive and traditional surgical approaches for refractory mesial temporal lobe epilepsy: A systematic review and meta-analysis of outcomes. Epilepsia. Apr 2021; 62(4): 831-845. PMID 33656182
30. Brotis AG, Giannis T, Paschalis T, et al. A meta-analysis on potential modifiers of LITT efficacy for mesial temporal lobe epilepsy: Seizure-freedom seems to fade with time. Clin Neurol Neurosurg. Apr 20 2021; 205: 106644. PMID 33962146
31. Grewal SS, Alvi MA, Lu VM, et al. Magnetic Resonance-Guided Laser Interstitial Thermal Therapy Versus Stereotactic Radiosurgery for Medically Intractable Temporal Lobe Epilepsy: A Systematic Review and Meta-Analysis of Seizure Outcomes and Complications. World Neurosurg. Feb 2019; 122: e32-e47. PMID 30244184
32. Xue F, Chen T, Sun H. Postoperative Outcomes of Magnetic Resonance Imaging (MRI)-Guided Laser Interstitial Thermal Therapy (LITT) in the Treatment of Drug-Resistant Epilepsy: A Meta- Analysis. Med Sci Monit. Dec 21 2018; 24: 9292-9299. PMID 30573725
33. Hoppe C, Helmstaedter C. Laser interstitial thermotherapy (LiTT) in pediatric epilepsy surgery. Seizure. Apr 2020; 77: 69-75. PMID 30591281
34. Hale AT, Sen S, Haider AS, et al. Open Resection versus Laser Interstitial Thermal Therapy for the Treatment of Pediatric Insular Epilepsy. Neurosurgery. Oct 01 2019; 85(4): E730-E736. PMID 30888028
35. Petito GT, Wharen RE, Feyissa AM, et al. The impact of stereotactic laser ablation at a typical epilepsy center. Epilepsy Behav. Jan 2018; 78: 37-44. PMID 29172137
36. Esmaeili B, Hakimian S, Ko AL, et al. Epilepsy-Related Mortality After Laser Interstitial Thermal Therapy in Patients With Drug-Resistant Epilepsy. Neurology. Sep 26 2023; 101(13): e1359-e1363. PMID 37202163
37. Kanner AM, Irving LT, Cajigas I, et al. Long-term seizure and psychiatric outcomes following laser ablation of mesial temporal structures. Epilepsia. Apr 2022; 63(4): 812-823. PMID 35137956
38. Landazuri P, Shih J, Leuthardt E, et al. A prospective multicenter study of laser ablation for drug resistant epilepsy - One year outcomes. Epilepsy Res. Nov 2020; 167: 106473. PMID 33045664
39. Wu C, Jermakowicz WJ, Chakravorti S, et al. Effects of surgical targeting in laser interstitial thermal therapy for mesial temporal lobe epilepsy: A multicenter study of 234 patients. Epilepsia. Jun 2019; 60(6): 1171-1183. PMID 31112302
40. Barnett G, Leuthardt E, Rao G, et al. American Association of Neurological Surgeons and Congress of Neurological Surgeons (AANS-CNS) Position Statement on MR-guided Laser Interstitial Thermal Therapy (LITT) for Brain Tumors and Radiation Necrosis. September 2021; https://www.aans.org/- /media/Files/AANS/Advocacy/PDFS/AANS-CNSPositionStatementPaperLITTTumor- Oncology090721.ashx. Accessed November 12, 2025.
41. Vogelbaum MA, Brown PD, Messersmith H, et al. Treatment for Brain Metastases: ASCO-SNO- ASTRO Guideline. J Clin Oncol. Feb 10 2022; 40(5): 492-516. PMID 34932393
42. Wu C, Schwalb JM, Rosenow J, et al. American Society for Stereotactic and Functional Neurosurgery Position Statement on Laser Interstitial Thermal Therapy for the Treatment of Drug-Resistant Epilepsy. September 2021; https://www.aans.org/- /media/Files/AANS/Advocacy/PDFS/ASSFNPositionStatementonLITTfortheTreatmentofDr ugResistantEpilepsy091321.ashx. Accessed October 11, 2024.
43. Elder JB, Nahed BV, Linskey ME, et al. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Role of Emerging and Investigational Therapties for the Treatment of Adults With Metastatic Brain Tumors. Neurosurgery. Mar 01 2019; 84(3): E201-E203. PMID 30629215
44. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology: Central Nervous System Cancers. Version 2.2025; https://www.nccn.org/professionals/phsician_gls/pdf/cns.pdf. Accessed November 18, 2025.
45. National Institute for Health and Care Excellence (NICE). Interventional procedures guidance: MRI- guided laser interstitial thermal therapy for drug-resistant epilepsy [IPG671]. March 4, 2020; https://www.nice.org.uk/guidance/ipg671. Accessed November 18, 2025.

7

46. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination: Laser Procedures (140.5). 1997; https://www.cms.gov/medicare-coverage- database/view/ncd.aspx?NCDId=69&ncdver=1&DocID=140.5. Accessed November 18, 2025.
47. Padda K, Matthews RE, Karakis I, Hewitt KC, Valentin E, Block C, Shade T, Dickey A, Millis S, Willie JT, Gross RE, Drane DL. Psychiatric changes after stereotactic laser amygdalohippocampotomy for medial temporal lobe epilepsy. Epilepsy Behav. 2023 Aug;145:109332. doi: 10.1016/j.yebeh.2023.109332. Epub 2023 Jul 8. PMID: 37422933; PMCID: PMC10523400.