ModifiedBlue Cross Blue Shield of VermontPolicy 7.01.VT170

Laser Interstitial Thermal Therapy for Neurological Conditions

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This policy governs coverage of laser interstitial thermal therapy (LITT) for refractory epilepsy, relapsed brain metastases, radiation necrosis, and glioblastoma, including criteria for medically necessary versus investigational use.

Policy Summary

PayerBlue Cross Blue Shield of Vermont

PolicyLaser Interstitial Thermal Therapy for Neurological Conditions

Policy CodePolicy 7.01.VT170

Change TypeNew policy

Effective DateAugust 1, 2026

Last ReviewApr 1, 2026

Next Review DateApril 1, 2027

Key ActionObtain prior approval for CPT 61736 or CPT 61737 before billing LITT procedures.

SourceLink

POLICY UPDATE CHANGES

A new policy established medical necessity criteria for LITT treatment of epilepsy, radiation necrosis, glioblastomas, and relapsed brain metastases.

A new coding table added CPT codes 61736 and 61737, both requiring prior approval.

4Neurological conditions addressed

2 or moreAntiepileptic drug regimens required for refractory epilepsy

2Minimum specialties on multidisciplinary team

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ModifiedBlue Cross Blue Shield of VermontPolicy 7.01.VT170

Laser Interstitial Thermal Therapy for Neurological Conditions

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Sign up for bcbsvermont Policy 7.01.VT170 alerts

Get alerted when Policy 7.01.VT170 changes without checking for updates manually.

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Policy Summary

PayerBlue Cross Blue Shield of Vermont

PolicyLaser Interstitial Thermal Therapy for Neurological Conditions

Policy CodePolicy 7.01.VT170

Change TypeNew policy

Effective DateAugust 1, 2026

Last ReviewApr 1, 2026

Next Review DateApril 1, 2027

Key ActionObtain prior approval for CPT 61736 or CPT 61737 before billing LITT procedures.

SourceLink

POLICY UPDATE CHANGES

A new policy established medical necessity criteria for LITT treatment of epilepsy, radiation necrosis, glioblastomas, and relapsed brain metastases.

A new coding table added CPT codes 61736 and 61737, both requiring prior approval.

4Neurological conditions addressed

2 or moreAntiepileptic drug regimens required for refractory epilepsy

2Minimum specialties on multidisciplinary team

All otherOther conditions considered investigational

Medical Necessity and Investigational Uses

Refractory epilepsy

LITT may be considered medically necessary for refractory epilepsy when ALL of the following are met.

All refractory epilepsy requirements

Clinical and treatment requirements
- Disabling seizures despite medication: There is documentation of disabling seizures despite use of 2 or more antiepileptic drug regimens.2 or more regimens
  Medication-refractory epilepsy
- Accessible epileptogenic focus: There are well-defined epileptogenic foci accessible by LITT.
- Multidisciplinary agreement: A multidisciplinary team of physicians that includes at least 2 specialties, such as neurology and neurosurgery, after considering all possible treatments, agrees that LITT is the best treatment option for the patient.At least 2 specialties

Relapsed brain metastases, radiation necrosis, and glioblastoma

LITT may be considered medically necessary for individuals who are poor candidates for craniotomy or resection when the condition and multidisciplinary-treatment criteria are met.

All brain tumor and radiation-necrosis requirements

Poor surgical candidacy: The individual is a poor candidate for craniotomy or resection.
Covered condition
- Relapsed brain metastases.
- Radiation necrosis.
- Glioblastoma.

Investigational uses

The following uses of LITT are considered investigational.

Investigational use

Listed condition without criteria: LITT is used for epilepsy, radiation necrosis, glioblastoma, or relapsed brain metastases but does not meet the stated medical-necessity criteria.
Other condition: LITT is used for any other condition.

LITT is considered investigational for all conditions other than epilepsy, radiation necrosis, glioblastoma, and relapsed brain metastases addressed by the policy criteria.

LITT is considered investigational when used for epilepsy, radiation necrosis, glioblastoma, or relapsed brain metastases but the applicable medical-necessity criteria are not met.

Covered LITT Procedure Codes

Covered CPT CodesCPTCovered

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	of lesion, intracranial, including burr hole(s), with magnetic resonance imaging guidance, when performed; multiple trajectories for multiple or complex lesion(s).

Authorization, Documentation, and Denial Risks

Note

Refractory Epilepsy Criteria

LITT for refractory epilepsy may be considered medically necessary only when all three requirements are met.

Documented disabling seizures despite 2 or more tolerated, appropriately chosen and used antiepileptic drug regimens.
Well-defined epileptogenic foci that are accessible by LITT.
A multidisciplinary team including at least 2 specialties, after considering all possible treatments, agrees LITT is the best option.

Note

Brain Tumor and Radiation-Necrosis Criteria

For relapsed brain metastases, radiation necrosis, or glioblastoma, LITT may be considered medically necessary only for individuals who are poor candidates for craniotomy or resection and whose treatment plan meets the multidisciplinary-review requirement.

The applicable condition must be relapsed brain metastases, radiation necrosis, or glioblastoma.
A multidisciplinary team including at least 2 specialists, such as neurosurgery and oncology, must determine LITT is the best option after considering relevant treatment approaches.

Laser Interstitial Thermal Therapy

Laser interstitial thermal therapy (LITT) uses a laser fiber introduced through a transcranial burr hole to deliver thermal energy and ablate targeted brain tissue. The fiber is positioned under MRI guidance, with real-time MR thermography used to monitor the treatment and control the ablation.

Key Clinical Terms

Disabling seizures

DefinitionSeizures that result in impairment or a loss of functional status.

Antiepileptic drug regimens

DefinitionTwo tolerated and appropriately chosen and used antiepileptic drug schedules, as monotherapies or in combination, used to achieve sustained seizure freedom.

Laser interstitial thermal therapy

DefinitionIntroduction of a laser fiber probe to deliver thermal energy for targeted ablation of diseased tissue, with probe position, ablation time, and intensity controlled under MRI guidance.

Policy Summary

PayerBlue Cross Blue Shield of Vermont

PolicyLaser Interstitial Thermal Therapy for Neurological Conditions

Policy CodePolicy 7.01.VT170

Change TypeNew policy

Effective DateAugust 1, 2026

Last ReviewApr 1, 2026

Next Review DateApril 1, 2027

Key ActionObtain prior approval for CPT 61736 or CPT 61737 before billing LITT procedures.

SourceLink

On This Page

Multidisciplinary agreement:

A multidisciplinary team of physicians including at least 2 specialists, such as neurosurgery and oncology, after considering all relevant possible treatment approaches, determines that LITT is the best treatment option.

At least 2 specialists

Prior Authorization

Prior Approval Required

Obtain prior approval before performing LITT procedures billed under CPT 61736 or CPT 61737.

CPT 61736: LITT of a single simple intracranial lesion using a single trajectory.
CPT 61737: LITT of multiple or complex intracranial lesions using multiple trajectories.

Documentation Required

Refractory Epilepsy Documentation

Authorization submissions for refractory epilepsy must establish both the severity of the seizures and the patient’s prior medication treatment history.

Document disabling seizures, defined as seizures causing impairment or loss of functional status.
Document 2 or more antiepileptic drug regimens; regimens must have been tolerated, appropriately chosen and used, as monotherapies or in combination, to achieve sustained seizure freedom.

Documentation Required

Tumor and Radiation-Necrosis Documentation

For brain metastases, radiation necrosis, or glioblastoma, provide documentation supporting the diagnosis, poor candidacy for craniotomy or resection, and the required treatment-planning review.

Document the applicable diagnosis: relapsed brain metastases, radiation necrosis, or glioblastoma.
Document that the individual is a poor candidate for craniotomy or resection.
Document agreement by a multidisciplinary team of at least 2 specialists that LITT is the best treatment option after relevant alternatives were considered.

Documentation Required

Provider Qualifications and Privileges

LITT must be performed by a neurosurgeon who meets the policy’s training and credentialing requirements.

Complete procedure-specific training in use of an FDA-approved LITT ablation system.
Hold hospital privileges to perform brain tumor surgery and LITT ablation procedures.

Prior Authorization

Complete Authorization Request

Submit a complete authorization request before treatment, including the clinical information needed to demonstrate that the applicable policy criteria are met. Incomplete requests may delay the determination while missing information is obtained.

Include the applicable diagnosis, clinical documentation, prior treatment history when relevant, surgical candidacy, treatment plan, multidisciplinary-team determination, and provider qualification information.
Verify the member’s benefits, limitations, exclusions, and applicable contract or plan requirements before providing the service.

Denial Risk

Does Not Meet Coverage Criteria

LITT is considered investigational when treatment for epilepsy, radiation necrosis, glioblastoma, or relapsed brain metastases does not meet the stated medical-necessity criteria. LITT is also investigational for all other conditions.

Do not represent LITT as meeting coverage criteria when the applicable condition-specific requirements are not satisfied.

Denial Risk

Required Clinical Criteria Absent

Missing required clinical criteria creates denial risk, including failure to establish the applicable condition, LITT-accessible treatment target, poor surgical candidacy where required, or multidisciplinary-team agreement.

Refractory epilepsy requires disabling seizures despite qualifying antiepileptic drug regimens and a well-defined epileptogenic focus accessible by LITT.
Brain tumor and radiation-necrosis cases require poor candidacy for craniotomy or resection, an applicable diagnosis, and multidisciplinary agreement that LITT is the best option.

Denial Risk

Audit Noncompliance

Blue Cross VT may audit providers and facilities for compliance with the medical policy. If an audit identifies noncompliance, Blue Cross VT may recoup all non-compliant payments.

Maintain documentation demonstrating compliance with the applicable medical-necessity, authorization, credentialing, and billing requirements.