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Medical Policy Search



Printer Friendly Version Intraperitoneal Hyperthermic Chemotherapy (IPHC)

Intraperitoneal Hyperthermic Chemotherapy (IPHC)

 

DESCRIPTION

Intraperitoneal hyperthermic chemotherapy (IPHC) is used as an adjunct to surgery for the treatment of gastrointestinal, appendiceal, ovarian, or mesothelial cancers that have penetrated or metastasized into the peritoneal cavity. The goal of IPHC is to enhance the cytotoxic effect of chemotherapeutic drugs and thereby kill disseminated tumor cells and reduce the risk of tumor recurrence.

 

POLICY

Cytoreduction and hyperthermic intraperitoneal chemotherapy for the treatment of peritoneal carcinomatosis of gastrointestinal origin is considered investigational.

 

POLICY EXCEPTIONS

None

 

POLICY GUIDELINES

Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

 

POLICY HISTORY

8/2001: Approved by Medical Policy Advisory Committee (MPAC)

2/13/2002: Investigational definition added

5/1/2002: Type of Service and Place of Service deleted

5/29/2002: Code Reference section completed

2/6/2007: Policy reviewed, no changes

9/20/2007: Code Reference section updated. ICD-9 2007 revisions added to policy

4/23/2009: Policy reviewed, no changes

10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.74 added to non-covered table. 

 

SOURCE(S)

Blue Cross Blue Shield Association policy # 2.03.07

Hayes Medical Technology Directory

 

CODE REFERENCE

All codes billed are considered investigational and not eligible for coverage.

Non-Covered Codes

*This is not an all inclusive list of non-covered procedure codes

 

Code Number

Description

CPT-4

77620

Hyperthermia generated by intracavitary probe(s)

ICD-9 Procedure

 

 

ICD-9 Diagnosis

151.0-151.9

Malignant neoplasm of stomach

152.0-153.9

Malignant neoplasm of intestine

159.0

Malignant neoplasm of intestinal tract, part unspecified

159.9

Malignant neoplasm of gastrointestinal tract unspecified

183.0-183.8

Malignant neoplasm of ovary

197.6

Secondary malignant neoplasm of peritoneal cavity

209.74

Secondary neuroendocrine tumor of peritoneum (New 10-1-2009)

789.51

Malignant ascites (new 10-1-2007)

HCPCS

 

 

 

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