Local or Whole Body Hyperthermia Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 08|01|2025 POLICY LAST REVIEWED: 04|02|2025 OVERVIEW Local hyperthermia for treatment of cancer consists of the use of heat to make tumors more susceptible to cancer therapy measures. Whole-body hyperthermia requires the patient to be placed under either general anesthesia or deep sedation. MEDICAL CRITERIA Medicare Advantage Plans Local hyperthermia therapy is considered medically necessary when the medical criteria in the online authorization tool is met.
Commercial Products Local hyperthermia may be considered medically necessary when used in connection with radiation therapy for the treatment primary or metastatic cutaneous or subcutaneous superficial malignancies. PRIOR AUTHORIZATION
Prior authorization is required for Medicare Advantage Plans and is recommended for Commerical Products. POLICY STATEMENT Medicare Advantage Plans Local hyperthermia therapy is considered medically necessary when the medical criteria in the online authorization tool is met.
Local hyperthermia therapy is considered not covered when the medical criteria in the online authorization tool is not met.
Commercial Products Local hyperthermia therapy is considered medically necessary when the medical criteria above is met. Local hyperthermia therapy may be considered not medically necessary when the medical criteria above is not met as the evidence is insufficient to determine the effects of the technology on health outcomes.
Local hyperthermia is not medically necessary when used alone or in connection with chemotherapy as the evidence is insufficient to determine the effects of the technology on health outcomes. Medicare Advantage Plans and Commercial Products Whole-body hyperthermia therapy is not covered for Medicare Advantage Plans and not medically necessary for Commercial products as as the evidence is insufficient to determine the effects of the technology on health outcomes. COVERAGE Benefits may vary between groups/contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage or Subscriber Agreement for the applicable radiation therapy benefits/coverage. BACKGROUND Medical Coverage Policy | Local or Whole Body Hyperthermia

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

Hyperthermia is a type of cancer treatment in which body tissue is exposed to high temperatures (up to 113°F) to damage and kill cancer cells. Hyperthermia can be administered using local and whole-body techniques. Local hyperthermia entails elevating the temperature of superficial or subcutaneous tumors while sparing surrounding normal tissue, using either external or interstitial modalities. Local hyperthermia therapy may be considered medically necessary when used in combination with radiation therapy for the treatment of patients with primary or metastatic cutaneous or subcutaneous superficial tumors. Local hyperthermia is considered not medically necessary when used alone or in combination with chemotherapy. Whole-body hyperthermia requires the patient to be placed under either general anesthesia or deep sedation. The patient’s body temperature is increased to 108°F by packing the patient in heated (hot water) blankets. The elevated body temperature is maintained for a period of 4 hours, while the essential body functions are closely monitored. Approximately 1 hour is required for a “cooling off” period, after which the patient is constantly observed for a minimum of 12 hours. This modality has been variously termed “systemic thermotherapy” or “whole-body hyperthermia.” Whole-body hyperthermia therapy is considered not medically necessary. There are inadequate data to permit scientific conclusions regarding the use of whole- body hyperthermia as an adjunct to either radiation or chemotherapy, and inadequate data regarding the use of local hyperthermia in conjunction with chemotherapy alone. CODING Medicare Advantage Plans and Commercial Products The following codes are medically necessary for local hyperthermia when the medical criteria above is met: 77600 Hyperthermia, externally generated; superficial (ie, heating to a depth of 4 cm or less) 77605 Hyperthermia, externally generated; deep (ie, heating to depths greater than 4 cm) 77610 Hyperthermia generated by interstitial probe(s); 5 or fewer interstitial applicators
77615 Hyperthermia generated by interstitial probe(s); more than 5 interstitial applicators 77620 Hyperthermia generated by intracavitary probe(s)

There is no specific CPT procedure code for whole-body hyperthermia. To report use an unlisted code.

RELATED POLICIES Prior Authorization via Web-Based Tool for Procedures Unlisted Procedures

PUBLISHED Provider Update, June 2025 Provider Update, March 2024 Provider Update, April 2023 Provider Update, June 2022 Provider Update, May, 2021

REFERENCES

1. Centers for Medicare and Medicaid Services (CMS) National Coverage Determination (NCD), Hyperthermia for Treatment of Cancer (110.1)
2. American Cancer Society: Hyperthermia to Treat Cancer https://www.cancer.org/cancer/managing- cancer/treatment-types/hyperthermia.html
3. National Cancer Institute: Hyperthermia to Treat Cancer, http://www.cancer.gov/cancertopics/factsheet/Therapy/hyperthermia
4. Overgaard J, Gonzalez Gonzalez D, Hulshof MC et al. Randomised trial of hyperthermia as adjuvant to radiotherapy for recurrent or metastatic malignant melanoma. European Society for Hyperthermic Oncology. Lancet 1995;345(8949):540-3.
5. Perez CA, Pajak T, Emami B et al. Randomized phase III study comparing irradiation and hyperthermia with irradiation alone in superficial measurable tumors. Final report by the Radiation Therapy Oncology Group. Am J Clin Oncol 1991;14(2):133-41.

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

6. Vernon CC, Hand JW, Field SB et al. Radiotherapy with or without hyperthermia in the treatment of superficial localized breast cancer: results from five randomized controlled trials. International Collaborative Hyperthermia Group. Int J Radiat Oncol Biol Phys 1996;35(4):731-44.
7. Emami B, Scott C, Perez CA et al. Phase III study of interstitial thermoradiotherapy compared with interstitial radiotherapy alone in the treatment of recurrent or persistent human tumors. A prospectively controlled randomized study by the Radiation Therapy Group. Int J Radiat Oncol Biol Phys 1996:34(5):1097-04.
8. Emami B, Stauffer P, Dewhirst M et al. RTOG quality assurance guidelines for interstitial hyperthermia. Int J Radiat Oncol Biol Phys 1991;20(5):1117-24.
9. Sherar M, Liu FF, Pintilie M et al. Relationship between thermal dose and outcome in thermoradiotherapy treatments for superficial recurrences of breast cancer: data from a phase III trial. Int J Radiat Oncol Biol Phys 1997;39(2):371-80.
10. Robins HI, Rushing D, Kutz M et al. Phase I clinical trial of melphalan and 41.8 degrees C whole-body hyperthermia in cancer patients. J Clin Oncol 1997;15(1):158-64.
11. Mittal BB, Zimmer MA, Sathiaseelan V et al. Phase I/II trial of combined 131I anti-CEA monoclonal antibody and hyperthermia in patients with advanced colorectal adenocarcinoma. Cancer 1996;78(9):1861-70.

12. Wiedemann GJ, Robins HI, Gutsche S et al. Ifosfamide, carboplatin and etoposide (ICE) combined with 41.8 degrees C whole body hyperthermia in patients with refractory sarcoma. Eur J Cancer 1996;32A(5):888-92. i

    This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS