CurrentBlue Cross Blue Shield of VermontPolicy 1.01.VT29

Tumor Treatment Fields for CNS Cancers Corporate Medical Policy

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This policy governs medical necessity and coverage of tumor treating fields therapy for selected CNS tumors, including glioblastoma and specified anaplastic gliomas, subject to member benefits and contract terms.

Policy Summary

PayerBlue Cross Blue Shield of Vermont

PolicyTumor Treatment Fields for CNS Cancers Corporate Medical Policy

Policy CodePolicy 1.01.VT29

Change TypeAdministrative and editorial revision

Effective DateJanuary 1, 2026

Last ReviewSep 1, 2025

Next Review DateSeptember 1, 2026

Key ActionObtain prior approval for HCPCS E0766 before requesting coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Covered clinical-use pathways

All other indicationsInvestigational designation

2HCPCS codes listed

Prior approvalRequired for HCPCS E0766

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CurrentBlue Cross Blue Shield of VermontPolicy 1.01.VT29

Tumor Treatment Fields for CNS Cancers Corporate Medical Policy

Customize your policy alerts

Sign up for bcbsvermont Policy 1.01.VT29 alerts

Get alerted when Policy 1.01.VT29 changes without checking for updates manually.

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Policy Summary

PayerBlue Cross Blue Shield of Vermont

PolicyTumor Treatment Fields for CNS Cancers Corporate Medical Policy

Policy CodePolicy 1.01.VT29

Change TypeAdministrative and editorial revision

Effective DateJanuary 1, 2026

Last ReviewSep 1, 2025

Next Review DateSeptember 1, 2026

Key ActionObtain prior approval for HCPCS E0766 before requesting coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Covered clinical-use pathways

All other indicationsInvestigational designation

2HCPCS codes listed

Prior approvalRequired for HCPCS E0766

Policy effective date

Medical Necessity and Investigational Uses

Medically Necessary Uses

Tumor treating fields therapy may be considered medically necessary when ALL of the following are met:

ALL of the following

The condition is one of the following
- Glioblastoma multiforme
- Anaplastic oligodendroglioma
- Anaplastic astrocytoma
- Anaplastic gliomas
The therapy is used in ONE of the following situations
- As an alternative to standard chemotherapy for progressive or recurrent disease after initial or repeat treatment with surgery, radiotherapy, and/or chemotherapy, when the disease is unresectable or resection is 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.

Investigational Indications

Tumor treating fields therapy is considered investigational when used for ALL indications other than the medically necessary uses specified above.

ALL of the following

The indication does not meet the specified medically necessary criteria for tumor treating fields therapy.

Indications outside the specified medically necessary uses are considered investigational.

Billing and Coding

Codes considered medically necessary when applicable criteria have been metHCPCSCovered

A4555	Electrode/transducer for use with electrical stimulation device used for cancer treatment, replacement only.
E0766	Electrical stimulation device used for cancer treatment, includes all accessories, any type.

A4555 Prior Approval

HCPCS codeA4555

Prior-approval thresholdOver the applicable dollar threshold per contract

Item descriptionElectrode/transducer for use with electrical stimulation device used for cancer treatment, replacement only

Authorization and Documentation Requirements

Prior Authorization

Verify Contract and Referral Authorization Requirements

Prior approval may be required, and benefits are subject to all terms, limitations, and conditions of the member’s subscriber contract. Verify applicable authorization requirements before providing the service.

An approved referral authorization is required for New England Health Plan (NEHP) members.
Prior approval is required for Access Blue New England (ABNE) members.
Member contract language takes precedence over this medical policy when there is a conflict.
Verify benefits for NEHP, ABNE, Federal Employee Program (FEP), and Administrative Services Only (ASO) members with the applicable health plan or employer benefit documents.

Prior Authorization

Prior Approval Required for E0766

Prior approval is required for the cancer-treatment electrical stimulation device billed under HCPCS E0766.

HCPCS E0766: Electrical stimulation device used for cancer treatment, including all accessories, any type.

Therapy Overview

Tumor treating fields (TTF) therapy is a noninvasive technology that uses electrical fields to treat certain cancers. It may be delivered in an outpatient setting or at home. This policy addresses selected central nervous system malignancies, including glioblastoma multiforme and specified anaplastic gliomas, and distinguishes covered medically necessary uses from investigational uses.

Key Terms

Tumor Treating Fields (TTF) Therapy

DefinitionA noninvasive technology intended to treat certain cancers using electrical fields

Intended useTreatment of glioblastoma, malignant pleural mesothelioma, and non-small cell lung cancer

Delivery settingOn an outpatient basis and at home

Glioblastoma Multiforme (GBM)

DefinitionThe most common and deadly malignant brain tumor

PrognosisVery poor prognosis

Quality of lifeAssociated with low quality of life during treatment

Treatment Setting

Salvage

Salvage treatment is covered when the following criterion is met.

Progressive or recurrent disease pathway: The patient has progressive or recurrent glioblastoma multiforme, anaplastic oligodendroglioma, anaplastic astrocytoma, or anaplastic gliomas after initial or repeat treatment with surgery, radiotherapy, and/or chemotherapy, and the disease is unresectable or resection is not recommended.

Tumor treating fields therapy is used as an alternative to standard chemotherapy.

Adjuvant

Adjuvant treatment is covered when the following criterion is met.

Adjuvant pathway: The patient has glioblastoma multiforme with supratentorial disease following initial treatment with surgery, radiotherapy, and/or chemotherapy.Supratentorial disease

Tumor treating fields therapy is used as adjuvant treatment to standard therapy.

Covered Treatment Pathways

Therapy use	Eligibility	Coverage
Tumor treating fields therapy as an alternative to standard chemotherapy
Progressive or recurrent glioblastoma multiforme, anaplastic oligodendroglioma, anaplastic astrocytoma, or anaplastic gliomas after initial or repeat treatment with surgery, radiotherapy, and/or chemotherapy, when the disease is unresectable or resection is not recommended.
Covered when criteria are met

Therapy use	Eligibility	Coverage
Tumor treating fields therapy as adjuvant treatment to standard therapy
Supratentorial glioblastoma multiforme following initial treatment with surgery, radiotherapy, and/or chemotherapy.
Covered when criteria are met

Therapy use	Eligibility	Coverage
Tumor treating fields therapy
All other indications.
Investigational

Policy Summary

PayerBlue Cross Blue Shield of Vermont

PolicyTumor Treatment Fields for CNS Cancers Corporate Medical Policy

Policy CodePolicy 1.01.VT29

Change TypeAdministrative and editorial revision

Effective DateJanuary 1, 2026

Last ReviewSep 1, 2025

Next Review DateSeptember 1, 2026

Key ActionObtain prior approval for HCPCS E0766 before requesting coverage.

SourceLink

On This Page

Confirm approval before dispensing or providing the device.

Billing Rule

Contract Threshold for Replacement Transducer

Prior approval is required for replacement transducer billed under HCPCS A4555 when the charge exceeds the applicable dollar threshold specified in the member’s contract.

HCPCS A4555: Electrode/transducer for use with an electrical stimulation device for cancer treatment, replacement only.
Apply the contract-specific dollar threshold and obtain prior approval when the threshold is exceeded.

Documentation Required

Submit Clinical Documentation Supporting Medical Necessity

Submit clinical documentation supporting the requested tumor treating fields therapy and demonstrating that the applicable medical-necessity criteria are met.

Document the diagnosis: glioblastoma multiforme, anaplastic oligodendroglioma, anaplastic astrocytoma, or anaplastic glioma.
Include treatment history, including initial or repeat surgery, radiotherapy, and/or chemotherapy.
For progressive or recurrent disease, document disease status and that the disease is unresectable or resection is not recommended.
For adjuvant treatment, document supratentorial disease and glioblastoma multiforme following initial surgery, radiotherapy, and/or chemotherapy.
Include relevant clinical evidence supporting the treatment plan and indication.

Denial Risk

Other Indications Are Investigational

Tumor treating fields therapy is considered investigational for all indications other than the specified medically necessary uses.

Coverage may be considered for the listed CNS cancers when used as an alternative to standard chemotherapy for qualifying progressive or recurrent disease, or as adjuvant treatment to standard therapy for qualifying supratentorial glioblastoma multiforme.
Indications outside these specified uses are investigational.

Denial Risk

Failure to Meet Medical-Necessity Criteria

Coverage may be denied when the requested service does not meet the medical-necessity criteria, including requirements related to the diagnosis, treatment history, disease status, tumor location, resectability, or treatment setting.

The qualifying diagnosis must be glioblastoma multiforme, anaplastic oligodendroglioma, anaplastic astrocytoma, or anaplastic glioma.
Alternative-to-chemotherapy use requires progressive or recurrent disease after initial or repeat surgery, radiotherapy, and/or chemotherapy, with disease that is unresectable or for which resection is not recommended.
Adjuvant use requires supratentorial disease and glioblastoma multiforme following initial surgery, radiotherapy, and/or chemotherapy.

Documentation Required

Complete the Authorization Request

Incomplete authorization requests may delay the coverage decision while missing information is requested. Submit all information needed to demonstrate that the policy guidelines are met.

Include the diagnosis, treatment history, disease status, resectability or recommendation against resection, tumor location, and applicable treatment setting.
Confirm that the authorization request is complete before submission.