HumanaCommercial Clinical Policy

Humana Electric Tumor Treatment Fields Form


Electric Tumor Treatment Fields (ETTFs)

Notes: Review for continued treatment is required every 90 days. For continued treatment, compliance with wearing the device at least 18 hours daily, no disease progression, and treatment within 24 months of initial treatment are required.

Indications

(940480) Has the patient been diagnosed with newly diagnosed glioblastoma multiforme (GBM) WHO grade IV astrocytoma, limited to the supratentorial region? 
(940481) Has the patient completed maximal debulking surgery and radiation therapy with concomitant standard of care chemotherapy? 
(940482) Is the patient being treated with a combination of ETTFs and temozolomide for newly diagnosed GBM, OR as monotherapy for recurrent GBM after exhausting surgical and radiation treatments? 
(940483) Is the patient 22 years of age or older? 
(940484) Has the patient or caregiver been trained and is able to apply and maintain the device for at least 18 hours per day? 

YesNoN/A
YesNoN/A
YesNoN/A

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Effective Date

02/02/2023

Last Reviewed

NA

Original Document

  Reference



Electric Tumor Treatment Fields

Medical Coverage Policy

Effective Date: 02/02/2023
Revision Date: 02/02/2023
Review Date: 02/02/2023

Policy Number: HUM-0517-013

Change Summary: Updated References

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.

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