Hyperthermia Therapy

POLICY NUMBER

L.2.01.413

DESCRIPTION

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.

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 heat (hot water) blankets. The elevated body temperature is maintained for a period of four hours while the essential body functions are closely monitored. Approximately one hour is required for a "cooling off" period after which the patient is constantly observed for a minimum of twelve hours. This modality has been variously termed "systemic thermotherapy" or "whole body hyperthermia."

POLICY

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 investigational when used alone or in combination with chemotherapy.

Whole body hyperthermia is considered investigational.

POLICY EXCEPTIONS

None

POLICY GUIDELINES

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

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

A.  consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and

B.  appropriate with regard to standards of good medical practice; and

C.  not solely for the convenience of the Member, his or her Provider; and

D.  the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.

POLICY HISTORY

3/1993: Issued.

3/29/2001: Policy reviewed; Managed Care Requirements deleted, Code Reference section, Source(s) and Type of Service updated.

2/14/2002: Investigational definition added.

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

9/20/2002: Policy reviewed; no changes.

1/17/2003: Policy reviewed; no changes based on Hayes report.

2/13/2004: Code Reference section updated, ICD-9 procedure code range 92.21-92.26 deleted.

2/20/2006: Code Reference table updated, CPT code 77620 added.

2/24/2006: Policy reviewed; no changes.

7/18/2008: Anesthesia Coding Policy hyperlink added.

9/28/2009: Coding Section updated with New ICD-9 Diagnosis Codes for 10-1-2009 added to Covered Codes Table- 209.31, 209.32, 209.33, 209.34, 209.35, 209.36, Verbiage added to Covered Codes Table,"* Some covered procedure codes may have multiple descriptions. Coverage will only be made for covered codes when used for services outlined within the policy statement section."

08/28/2015: Code Reference section updated for ICD-10. Extended ICD-9 diagnosis codes 173.0-173.9  to the fifth digit.

10/09/2015: Code Reference section updated to make the following correction: ICD-10 procedure code DWY48ZZ changed to DWY68ZZ.

04/26/2016: Policy Guidelines updated to add medically necessary and investigative definitions.

06/06/2016: Policy number L.2.01.413 added.

09/30/2016: Code Reference section updated to add new ICD-10 diagnosis codes C49.A0 - C49.A9.

05/17/2018: Coding policy link updated in Code Reference section.

09/24/2018: Code Reference section updated to add new ICD-10 diagnosis codes C44.1021, C44.1022, C44.1091, C44.1092, C4A.111, C4A.112, C4A.121, C4A.122, D04.111, D04.112, D04.121, and D04.122, effective 10/01/2018.

11/07/2022: Policy reviewed. Policy statements unchanged. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity." Code Reference section updated to remove deleted ICD-10 diagnosis codes C44.102, C44.109, C4A.11, C4A.12, D04.11, and D04.12.

10/31/2023: Policy reviewed; no changes.

12/05/2024: Policy reviewed; no changes.

SOURCE(S)

1. Blue Cross Blue Shield Association policy #2.01.05

2. Hayes Medical Technology Directory

3. Uniform Medical Policy Manual (11/1989)

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.

For Coding Guidelines see the Anesthesia Coding Policy .

Covered Codes

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