Tumor Treatment Fields Therapy for CNS Cancers Form

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Medical Policy Number: 1.01.VT29

Tumor Treatment Fields for CNS Cancers
Corporate Medical Policy

File Name: Tumor Treatment Fields for CNS Cancers
File Code: 1.01.VT29 Origination: 06/2018
Last Review: 09/2025 Next Review: 09/2026 Effective Date: 01/01/2026

Description/Summary

Tumor treating fields (TTF) therapy is a noninvasive technology intended to treat glioblastoma, malignant pleural mesothelioma, and non small cell lung cancer on an outpatient basis and at home using electrical fields. Glioblastoma multiforme (GBM) is the most common and deadly malignant brain tumor. It has a very poor prognosis and is associated with low quality of life during treatment.

Policy Coding Information Click the links below for attachments, coding tables & instructions. Attachment I – Coding Table

When a service may be considered medically necessary

Tumor treating fields therapy to treat glioblastoma multiforme, anaplastic oligodendroglioma, anaplastic astrocytoma, and anaplastic gliomas may be considered medically necessary in the following situations:

• As an alternative to standard chemotherapy for patients with progressive or recurrent glioblastoma multiforme, anaplastic oligodendroglioma, anaplastic astrocytoma, and anaplastic gliomas after initial or repeat treatment with surgery, radiotherapy, and/or chemotherapy when disease is unresectable or resection not recommended. • As adjuvant treatment to standard therapy in patients with supratentorial disease and glioblastoma multiforme following initial treatment with surgery, radiotherapy, and/or chemotherapy.

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Medical Policy Number: 1.01.VT29

When a service is considered investigational

Tumor treating fields therapy is considered investigational for ALL other indications.

Policy Guidelines

There are no specific codes for the initial application of this system or instruction on use. The patient reapplies the transducer arrays at home after the initial instruction.

Reference Resources

1. Blue Cross Blue Shield Association Medical Policy Reference Manual: 1.01.29 - Tumor Treating Fields Therapy. Last reviewed 08/2025. Accessed 09/2025.

2. National Cancer Institute (NCI). Adult Central Nervous System Tumors Treatment (PDQ®)– Health Professional Version 3 2020. https://www.nccn.org/professionals/physician_gls/pdf/cns.pdf. Accessed 10/30/20.

   Document Precedence

   Blue Cross and Blue Shield of Vermont (Blue Cross VT) Medical Policies are developed to provide clinical guidance and are based on research of current medical literature and review of common medical practices in the treatment and diagnosis of disease. The applicable group/individual contract and member certificate language, or employer’s benefit plan if an ASO group, determines benefits that are in effect at the time of service. Since medical practices and knowledge are constantly evolving, Blue Cross VT reserves the right to review and revise its medical policies periodically. To the extent that there may be any conflict between medical policy and contract/employer benefit plan language, the member’s contract/employer benefit plan language takes precedence.

   Audit Information Blue Cross VT reserves the right to conduct audits on any provider and/or facility to ensure compliance with the guidelines stated in the medical policy. If an audit identifies instances of non-compliance with this medical policy, Blue Cross VT reserves the right to recoup all non- compliant payments. Administrative and Contractual Guidance Benefit Determination Guidance

   Prior approval may be required and benefits are subject to all terms, limitations and conditions of the subscriber contract.

   Incomplete authorization requests may result in a delay of decision pending submission of missing information. To be considered compete, see policy guidelines above.

   An approved referral authorization for members of the New England Health Plan (NEHP) is required. A prior approval for Access Blue New England (ABNE) members is required.

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Medical Policy Number: 1.01.VT29

NEHP/ABNE members may have different benefits for services listed in this policy. To confirm benefits, please contact the customer service department at the member’s health plan.

Federal Employee Program (FEP): Members may have different benefits that apply. For further information please contact FEP customer service or refer to the FEP Service Benefit Plan Brochure. It is important to verify the member’s benefits prior to providing the service to determine if benefits are available or if there is a specific exclusion in the member’s benefit.

Coverage varies according to the member’s group or individual contract. Not all groups are required to follow the Vermont legislative mandates. Member Contract language takes precedence over medical policy when there is a conflict.

If the member receives benefits through an Administrative Services Only (ASO) group, benefits may vary or not apply. To verify benefit information, please refer to the member’s employer benefit plan documents or contact the customer service department. Language in the employer benefit plan documents takes precedence over medical policy when there is a conflict.

Policy Implementation/Update information

06/2018 New Policy, input received from external network specialty providers. 10/2020 No change to policy statement. 10/2021 Policy Reviewed. Updated references. No change to policy statement. 09/2022 Policy Reviewed. References updated. No change to policy statement. 09/2023 Policy reviewed. References updated. No changes to policy statement. 09/2024 Policy reviewed. References updated. No changes to policy statement. 09/2025 Policy reviewed. Minor grammatical changes and updates to summary section made. References updated. No changes to policy statement.

Eligible providers

Qualified healthcare professionals practicing within the scope of their license(s).

Approved by Blue Cross VT Medical Director(s )

Tom Weigel, MD, MBA Vice President and Chief Medical Officer

Tammaji P. Kulkarni, MD Senior Medical Director

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Medical Policy Number: 1.01.VT29

Attachment I Coding Table

Code Type Number Brief Description Policy Instructions The following codes are considered as medically necessary when applicable criteria have been met. HCPCS A4555 Electrode/transducer for use with electrical stimulation device used for cancer treatment, replacement only Prior Approval Required if over the following dollar threshold per contract. HCPCS E0766 Electrical stimulation device used for cancer treatment, includes all accessories, any type Requires Prior Approval