Humana Laser Interstitial Thermal Therapy Form

Description

Laser interstitial thermal therapy (LITT) is a minimally invasive treatment using a focused beam of electromagnetic radiation emitted from a laser that is stereotactically placed into a targeted location. Other terms for LITT include, but may not be limited to, focal laser therapy, interstitial laser ablation, interstitial laser coagulation, interstitial laser photocoagulation, laser induced thermal therapy and MRI-guided laser interstitial thermal therapy (MRgLITT).

In LITT, the laser energy is converted into thermal energy and is designed to ablate the target minimizing injury to the surrounding tissues. Magnetic resonance imaging (MRI) thermography is used during the procedure to monitor tissue temperatures and to protect the healthy tissue surrounding the target. The use of LITT is expanding to include the treatment of an individual with medically refractory epileptic seizures or epileptogenic foci (site of the brain in which the seizure originated) that are not accessible with conventional surgical tools.

LITT devices

LITT devices consist of a cooled fiberglass catheter, an external laser generator and a control console.

Examples of LITT systems include the Visualase Thermal Therapy System and the NeuroBlate system.

Applications of LITT

Applications of LITT currently being researched include, but may not be limited to, benign or malignant tumors or nodules (eg, brain, breast, thyroid), cancer (eg, liver, lung, prostate, renal, thyroid), osteoid osteoma or radiation necrosis. (Refer to Coverage Limitations section)

For information regarding benign prostate hyperplasia and interstitial laser coagulation, please refer to Benign Prostatic Hyperplasia Treatments Medical Coverage Policy.

Coverage Determination

Humana members may be eligible under the Plan for laser interstitial thermal therapy for the treatment of epilepsy when the following criteria are met:

• Absence of contraindications; AND
• Documentation of the failure to respond to, or intolerance of at least 2 or more antiepileptic drug regimens resulting in disabling seizures; AND
• Documentation of well-defined epileptogenic foci that is accessible by LITT (eg, MRI, electroencephalography [EEG]); AND
• Documentation that treatment using LITT has been agreed upon by a multidisciplinary team (including a neurosurgeon and neurologist) and after all treatment approaches have been considered, LITT has been determined to be the best treatment option.

Coverage Limitations

Humana members may NOT be eligible under the Plan for laser interstitial thermal therapy for any indications other than those listed above including, but may not be limited to:

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• Brain tumors (malignant: primary and metastatic) OR
• Breast tumors (benign, malignant); OR
• Liver cancer (primary and metastatic); OR
• Lung cancer (primary and metastatic); OR
• Osteoid osteoma; OR
• Prostate cancer; OR
• Radiation necrosis; OR
• Renal cancer; OR
• Thyroid tumors or nodules (benign, malignant)

This is considered experimental/investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for laser interstitial thermal therapy for the following contraindications:

• Inability to identify the epileptogenic foci or critical pathways within epileptogenic networks; OR
• Inability to undergo MRI because of medical reasons (eg, aneurysm clips, implanted medication [insulin] pumps, pacemaker); OR
• Medical contraindications to surgery (eg, unstable cardiac or respiratory conditions, anticoagulants that cannot be discontinued)

These are considered experimental/investigational as they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Background

Additional information about brain and breast tumors, epilepsy, liver, lung, prostate, renal cancer, thyroid cancer, osteoid osteoma and radiation necrosis may be found from the following websites:

• American Academy of Neurology
• American Urological Association
• National Cancer Institute
• National Library of Medicine

Medical Alternatives

Physician consultation is advised to make an informed decision based on an individual's health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for services rendered.

Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.

CPT® Code(s)

• 19499 - Unlisted procedure, breast - Not Covered if used to report laser interstitial thermal therapy
• 20999 - Unlisted procedure, musculoskeletal system, general - Not Covered if used to report laser interstitial thermal therapy
• 32999 - Unlisted procedure, lungs and pleura - Not Covered if used to report laser interstitial thermal therapy
• 47399 - Unlisted procedure, liver - Not Covered if used to report laser interstitial thermal therapy
• 55899 - Unlisted procedure, male genital system - Not Covered if used to report laser interstitial thermal therapy
• 60699 - Unlisted procedure, endocrine system - Not Covered if used to report laser interstitial

Laser Interstitial Thermal Therapy Effective Date: 03/01/2023 Revision Date: 03/01/2023 Review Date: 03/01/2023 Policy Number: HUM-0572-007 Page: 5 of 9

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

64999

• Unlisted procedure, nervous system - Not Covered if used to report laser interstitial thermal therapy
• 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)
• CPT® Category Ill Code(s)
• O655T - Transperineal focal laser ablation of malignant prostate tissue, including transrectal imaging guidance, with MR-fused images or other enhanced ultrasound imaging - Not Covered
• 0673T - Ablation, benign thyroid nodule(s), percutaneous, laser, including imaging guidance - Not Covered
• HCPCS Code(s)

References

• American Society for Radiation Oncology (ASTRO). Treatment for brain metastases: ASCO-SNO-ASTRO guideline. www.astro.org. Published December 21, 2021. Accessed January 24, 2023.
• American Society for Stereotactic and Functional Neurosurgery (ASSFN). The American Society for Stereotactic and Functional Neurosurgery position statement on laser interstitial thermal therapy for the treatment of drug-resistant epilepsy. www.assfn.org. Published February 2022. Accessed January 23, 2023.
• American Society of Breast Surgeons. Consensus guideline on the use of transcutaneous and percutaneous ablation for the treatment of benign and

• American Society of Breast Surgeons. Consensus guideline on the use of transcutaneous and percutaneous ablation for the treatment of benign and malignant tumors of the breast. www.breastsurgeons.org. Published October 16, 2018. Accessed January 24, 2023.
• American Urological Association. Renal mass and localized renal cancer. www.auanet.org. Published April 2017. Accessed January 25, 2023.
• ClinicalKey. Kaidar-Person, Cools M, Zagar T. Brain metastases and neoplastic meningitis. In: Niederhuber JE, Armitage JO, Doroshow JH, Kastan MB, Tepper JE. Abeloff’s Clinical Oncology. 6th ed. Elsevier; 2020:794-808.e3. www.clinicalkey.com. Accessed January 19, 2023.
• Congress of Neurological Surgeons. Congress of Neurological Surgeons systematic review and evidenced-based guideline on the role of emerging and investigational therapies for the treatment of adults with metastatic brain tumors. www.cns.org. Published January 9, 2019. Accessed January 23, 2023.
• Congress of Neurological Surgeons. Position statement on MR-guided laser interstitial thermal therapy (LITT) for brain tumors and radiation necrosis. www.cns.org. Published September 7, 2021. Accessed January 23, 2023.
• ECRI Institute. Clinical Evidence Assessment. Laser interstitial thermal therapy for breast cancer. www.ecri.org. Published January 14, 2019. Updated March 1, 2021. Accessed January 18, 2023.
• ECRI Institute. Clinical Evidence Assessment. Laser interstitial thermal therapy for epilepsy. www.ecri.org. Published September 10, 2019. Updated July 27, 2021. Accessed January 18, 2023.
• ECRI Institute. Clinical Evidence Assessment. Laser interstitial thermal therapy for glioblastoma. www.ecri.org. Published January 18, 2019. Updated October 25, 2021. Accessed January 18, 2023.
• ECRI Institute. Clinical Evidence Assessment. Laser interstitial thermal therapy for localized prostate cancer. www.ecri.org. Published January 7, 2019. Updated February 1, 2022. Accessed January 18, 2023.
• ECRI Institute. Clinical Evidence Assessment. Laser interstitial thermal therapy for metastases to the liver. www.ecri.org. Published January 14, 2019. Updated March 10, 2021. Accessed January 18, 2023.
• ECRI Institute. Clinical Evidence Assessment. Laser interstitial thermal therapy for metastatic lung cancer. www.ecri.org. Published January 14, 2019. Updated March 10, 2021. Accessed January 18, 2023.
• ECRI Institute. Clinical Evidence Assessment. Laser interstitial thermal therapy for nonglioblastoma brain cancers. www.ecri.org. Published January 14, 2019. Updated August 8, 2022. Accessed January 18, 2023.
• ECRI Institute. Clinical Evidence Assessment. Laser interstitial thermal therapy for osteoid osteoma. www.ecri.org. Published January 11, 2019. Updated January 12, 2023. Accessed January 18, 2023.
• Hayes, Inc. Evolving Evidence Review. Laser interstitial thermal therapy for treatment of recurrent metastatic brain neoplasms. evidence.hayesinc.com. Published January 12, 2023. Accessed January 18, 2023.
• Hayes, Inc. Evolving Evidence Review. Laser interstitial thermal therapy (LITT) for treatment of brain radiation necrosis. evidence.hayesinc.com. Published January 18, 2023. Accessed January 18, 2023.
• Hayes, Inc. Health Technology Assessment. Laser interstitial thermal therapy for refractory temporal lobe epilepsy. evidence.hayesinc.com. Published February 19, 2020. Updated January 20, 2023. Accessed January 23, 2023.

• Laser interstitial thermal therapy (LITT) for treatment of glioblastoma in adults. evidence.hayesinc.com. Published September 20, 2019. Updated October 31, 2022. Accessed January 18, 2023.
• National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Central nervous system cancers. www.nccn.org. Published September 29, 2022. Accessed January 24, 2023.
• National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Melanoma (uveal). www.nccn.org. Published April 5, 2022. Accessed January 24, 2023.
• UpToDate, Inc. Cystic thyroid nodules. www.uptodate.com. Updated December 2022. Accessed January 26, 2023.
• UpToDate, Inc. Delayed complications of cranial irradiation. www.uptodate.com. Updated December 2022. Accessed January 18, 2023.
• UpToDate, Inc. Image-guided ablation of skeletal metastases. www.uptodate.com. Updated January 5, 2023. Accessed January 18, 2023.
• UpToDate, Inc. Management of recurrent high-grade gliomas. www.uptodate.com. Updated January 17, 2023. Accessed January 18, 2023.
• UpToDate, Inc. Nonsurgical local treatment strategies for colorectal liver metastases. www.uptodate.com. Updated December 13, 2022. Accessed January 26, 2023.
• UpToDate, Inc. Overview of the treatment of brain metastases. www.uptodate.com. Updated December 12, 2022. Accessed January 18, 2023.
• UpToDate, Inc. Surgical treatment of epilepsy in adults.www.uptodate.com. Updated December 2022. Accessed January 18, 2023.
• UpToDate, Inc. The role of local therapies in metastatic breast cancer. www.uptodate.com. Updated December 2022. Accessed January 26, 2023.