Currentblue cross blue shield - louisianaPolicy MA-220

Laser Interstitial Thermal Therapy for Neurological Conditions

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This policy describes coverage and investigational determinations for MR-guided laser interstitial thermal therapy (LITT/MRgLITT) for neurological conditions, specifying criteria for coverage in drug-resistant disabling epilepsy and deeming other indications investigational; it applies to all products under the Health Plan unless contract exceptions apply.

Policy Summary

Payerblue cross blue shield - louisiana

PolicyLaser Interstitial Thermal Therapy for Neurological Conditions

Policy CodePolicy MA-220

Change TypeNo material change

Effective DateAug 1, 2026

Last ReviewMay 19, 2026

Next Review DateMay 19, 2026

Key ActionObtain prior authorization documenting failure of ≥2 antiepileptic drug regimens, confirmation of 1–2 accessible epileptogenic foci, and multidisciplinary agreement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2+minimum failed antiepileptic drug regimens required for LITT coverage in epilepsy

1-2number of epileptogenic foci allowed for covered LITT in epilepsy

Visualase, NeuroBlateFDA-cleared LITT systems named in policy

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Currentblue cross blue shield - louisianaPolicy MA-220

Laser Interstitial Thermal Therapy for Neurological Conditions

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Sign up for blue cross blue shield - louisiana Policy MA-220 alerts

Get alerted when Policy MA-220 changes without checking for updates manually.

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Policy Summary

Payerblue cross blue shield - louisiana

PolicyLaser Interstitial Thermal Therapy for Neurological Conditions

Policy CodePolicy MA-220

Change TypeNo material change

Effective DateAug 1, 2026

Last ReviewMay 19, 2026

Next Review DateMay 19, 2026

Key ActionObtain prior authorization documenting failure of ≥2 antiepileptic drug regimens, confirmation of 1–2 accessible epileptogenic foci, and multidisciplinary agreement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2+minimum failed antiepileptic drug regimens required for LITT coverage in epilepsy

1-2number of epileptogenic foci allowed for covered LITT in epilepsy

Visualase, NeuroBlateFDA-cleared LITT systems named in policy

Epilepsy: covered; Others: investigational

coverage stance by indication

61736, 61737Procedure codes listed

Prior auth req'dAuthorization requirement

Coverage Criteria and Evidence-Based Guidance

Coverage for drug-resistant disabling epilepsy

Covered when ALL of the following are met:

Epilepsy LITT coverage criteria: Evidence of medically refractory and disabling epilepsy with documented failure to respond to at least 2 tolerated antiepileptic drug regimens; AND Confirmed well-defined 1-2 epileptogenic foci accessible by MRgLITT; AND Treatment plan to use LITT as the best treatment option for the patient has been agreed upon by a multidisciplinary team of at least 2 specialists (e.g., neurosurgery and neurology).

Seizures are considered medically refractory when 2 appropriately chosen and used drug schedules (monotherapies or in combination) failed to achieve sustained seizure freedom; disabling when causing impairment or loss of functional status.

Coverage considerations and society guidance

Coverage considerations informed by professional society guidance:

Society-supported indications: MRgLITT may be considered for patients who are poor surgical candidates for craniotomy/resection; potential indications cited include relapsed brain metastases, radiation necrosis, glioblastoma, and other gliomas (NCCN Category 2B).

NCCN guidance (v.3.2024)

Radiation necrosis pathway: For corticosteroid-refractory radiation necrosis, LITT can be considered; international SRS Society recommendations suggest reserving LITT for patients refractory to noninvasive therapies (e.g., bevacizumab, hyperbaric oxygen) or as invasive therapy for more severe cases.

International SRS Society (2024)

Epilepsy criteria (ASSFN): Consider MRgLITT for drug-resistant, localization-related epilepsy only after failure or intolerance of at least 2 appropriately chosen antiseizure medications at appropriate doses and when well-defined epileptogenic foci or critical propagation pathways are accessible by MRgLITT.≥2 medications failed

ASSFN position statement (Sept 2021)

Evidence insufficiency caution: Some neurosurgery societies and CNS guidelines state there is insufficient evidence to recommend routine use of LITT for brain metastases and related indications outside approved clinical trials (no recommendation).

AANS/CNS and ASCO/SNO/ASTRO statements

Investigational: The Health Plan considers LITT to be investigational and not covered for neurological indications other than drug‑resistant disabling epilepsy meeting the policy's coverage criteria. This includes, but is not limited to, patients with primary or metastatic brain tumors and radiation necrosis.

Requests for LITT for drug‑resistant disabling epilepsy when the specific coverage criteria are not met are also considered investigational and are not covered.

Professional society guidance cautions about routine use of LITT outside clinical trials. The Congress of Neurological Surgeons states there is insufficient evidence to make a recommendation regarding routine use of LITT except as part of approved clinical trials, and other society guidance (e.g., ASCO/SNO/ASTRO) similarly makes no recommendation for or against LITT for brain metastases based on low‑quality evidence.

Accordingly, routine application of LITT outside of approved clinical trials is not recommended by these guidelines and may be considered unsupported for coverage in some contexts.

Per the policy definition, treatments deemed Investigational are excluded from being considered medically necessary until sufficient evidence demonstrates effectiveness. The policy's investigational determinations for LITT therefore preclude coverage for those indications until additional high‑quality evidence and consensus support routine use.

The Health Plan applies the investigational definition using factors such as FDA status, need for further study, and consensus evidence from peer‑reviewed literature when determining exclusions.

Use of LITT for neurological indications other than drug‑resistant disabling epilepsy that meets the policy criteria is considered investigational and is not covered. Examples specifically called out include primary brain tumors, metastatic brain tumors, and radiation necrosis, among other non‑epilepsy indications.

Requests for these indications will be denied as investigational unless and until coverage criteria or supporting evidence change.

Multiple guideline statements note that available evidence is insufficient to support routine use of LITT outside of approved clinical trials. ASCO/SNO/ASTRO concluded that no recommendation can be made for or against LITT for brain metastases, and CNS guidelines state there is insufficient evidence to justify routine use except within trials.

Because of these guideline conclusions, routine use of LITT outside clinical research should not be assumed to meet medical necessity and may be excluded from coverage.

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior authorization required to confirm benefits and eligibility for epilepsy LITT

Prior authorization is required to confirm benefits and verify that the member meets coverage criteria for LITT in drug‑resistant disabling epilepsy, including documented failure of at least two tolerated antiepileptic drug regimens, confirmation of 1–2 well‑defined epileptogenic foci accessible by MRgLITT, and multidisciplinary agreement that LITT is the best treatment option.

Prior authorization confirms member contract benefits and medical necessity.
Prior authorization must verify: failure of ≥2 AED regimens; 1–2 accessible epileptogenic foci; multidisciplinary team agreement.

Prior Authorization

Document prior treatments, surgical candidacy, and multidisciplinary input with prior authorization

Submit documentation of prior treatments and surgical candidacy with the prior authorization request; include evidence of previous medical therapies tried and whether the patient is a candidate for open craniotomy/resection, and note multidisciplinary consultation when applicable.

Procedure and Diagnosis Codes

Codes used to identify services associated with this policyCPT

61736	exact code listed in policy
61737	exact code listed in policy

Associated diagnosis codesICD-10

All related diagnoses

ICD-10 diagnoses associated with this policy (policy lists 'All related diagnoses')

Background and Context

Laser interstitial thermal therapy (LITT, also called MR‑guided LITT) is a minimally invasive procedure that delivers targeted thermal ablation of intracranial tissue via a laser fiber probe introduced through a burr hole and monitored with real‑time MRI thermography. Cooling of the applicator minimizes collateral thermal injury while MR guidance allows visualization of the ablation zone during the procedure.

LITT is most commonly used for well‑defined epileptogenic foci, primary and metastatic brain tumors, and radiation necrosis in surgically inaccessible or eloquent brain regions; it may reduce morbidity compared with open craniotomy but carries risks including weakness, cerebral edema, hemorrhage, seizures, and hyponatremia. MRI contraindications also apply.

Terms and Definitions

LITT / MRgLITT definition

Procedure nameLaser interstitial thermal therapy (LITT), also called MR‑guided LITT (MRgLITT)

What it isMinimally invasive procedure in which a laser fiber probe is introduced via a transcranial burr hole to deliver targeted thermal energy to ablate diseased intracranial tissue under MRI guidance

How ablation is monitored and controlledReal‑time MR thermography is used to monitor temperature and maintain a sharp thermal border; actively cooled applicators control energy delivery

Typical indications described in literatureAblation of epileptogenic foci, primary and metastatic brain tumors, and radiation necrosis in surgically inaccessible or eloquent brain areas

Common complications/contraindicationsComplications include weakness, cerebral edema, hemorrhage, seizures, hyponatremia; contraindications include MRI incompatibility

Policy Summary

Payerblue cross blue shield - louisiana

PolicyLaser Interstitial Thermal Therapy for Neurological Conditions

Policy CodePolicy MA-220

Change TypeNo material change

Effective DateAug 1, 2026

Last ReviewMay 19, 2026

Next Review DateMay 19, 2026

Key ActionObtain prior authorization documenting failure of ≥2 antiepileptic drug regimens, confirmation of 1–2 accessible epileptogenic foci, and multidisciplinary agreement.

SourceLink

On This Page

Document prior antiepileptic medication trials and responses.

Document assessment of candidacy for craniotomy/resection and any multidisciplinary consultation (e.g., neurosurgery and neurology).

Prior Authorization

CPT 61736 and 61737 require prior authorization

Requests billing CPT codes 61736 or 61737 must have prior authorization before services are rendered.

All codes listed on the Medical Policy require prior authorization; CPT 61736 and 61737 are included in the policy's code list.

Step Therapy

Must document failure of ≥2 appropriate antiepileptic drug regimens

Documented failure of at least two appropriately chosen and used antiepileptic drug regimens (monotherapy or combination) is required before LITT will be considered for epilepsy.

'Medically refractory' defined as failure of 2 appropriately chosen and used drug schedules to achieve sustained seizure freedom.

Step Therapy

Reserve LITT for radiation necrosis after failure of noninvasive therapies

For radiation necrosis, LITT should be considered only after failure of noninvasive therapies per international guidance (e.g., corticosteroids, bevacizumab, hyperbaric oxygen) or when invasive therapy is indicated for more severe symptoms.

International SRS Society suggests LITT for corticosteroid‑refractory symptoms after noninvasive therapy.
NCCN notes LITT can be considered case‑by‑case for radiation necrosis and recommends neurosurgical consultation.

Documentation Required

Required documentation to support epilepsy coverage

Provide documentation demonstrating medically refractory and disabling epilepsy: failure of at least two tolerated antiepileptic drug regimens, confirmation of 1–2 well‑defined epileptogenic foci accessible to MRgLITT, and a multidisciplinary treatment plan agreed upon by at least two specialists (e.g., neurosurgery and neurology).

Include clinical evidence that seizures are disabling (impairment or loss of functional status).
Confirm focal localization (1–2 foci) and accessibility for MRgLITT.

Documentation Required

Document clinical justification and prior treatments supporting MRgLITT

Include clinical justification that the patient is a poor candidate for open surgical resection or that they meet society‑stated criteria for MRgLITT (e.g., refractory epilepsy with failure of ≥2 appropriate medications and a well‑defined, accessible epileptogenic focus); for other indications, document biopsy‑proven radiation necrosis when applicable.

Document why craniotomy/resection is not appropriate or feasible.
Reference relevant society guidance (ASSFN, NCCN, International SRS Society) when applicable.

Documentation Required

Provide prior‑plan authorization documentation to allow 90‑day coverage transition

When a member transfers plans and has an ongoing authorized course of LITT, provide the prior plan's authorization documentation to permit a 90‑day in‑network transition of the authorized treatment.

Documentation of the previous plan's authorization must be provided by the member or provider.
Services must otherwise be covered under the receiving plan to qualify for the 90‑day transition.

Denial Risk

LITT requests for non‑covered indications are investigational and will be denied

Requests for LITT for indications other than drug‑resistant disabling epilepsy (or where coverage criteria are unmet) are considered investigational and are not covered; such requests will be denied.

Policy states LITT for all other neurological indications (including primary/metastatic brain tumors and radiation necrosis) is investigational when criteria are not met.
Coverage is not available for investigational treatments per policy rules.

Denial Risk

Insufficient evidence for routine use may lead to denial outside trials

Clinical guidelines (e.g., Congress of Neurological Surgeons) state there is insufficient evidence to recommend routine use of LITT outside approved clinical trials; claims for routine use where evidence/guidance indicates insufficiency may be denied.

CNS guidelines state insufficient evidence to make a recommendation for routine use of LITT outside clinical trials.
Routine use outside approved trials may be considered exclusionary for coverage in some contexts.

Denial Risk

Not obtaining prior authorization risks claim denial

Failure to obtain required prior authorization may result in claim denial; the policy notes that all codes listed on the Medical Policy require prior authorization to ensure appropriate utilization and alignment with guidelines.

Notice that all codes listed on the Medical Policy require prior authorization.
Claims submitted without prior authorization are at risk for denial.

Medically refractory (seizures)

DefinitionSeizures are considered medically refractory when 2 appropriately chosen and used drug schedules (monotherapy or in combination) have failed to achieve sustained seizure freedom

Disabling seizuresSeizures are considered disabling when causing impairment or loss of functional status

Context for LITT coverageDocumentation must show failure of at least 2 tolerated antiepileptic drug regimens to meet coverage criteria for epilepsy

MRgLITT — alternate definition

Alternate nameMagnetic resonance‑guided laser interstitial thermal therapy (MRgLITT)

DescriptionMinimally invasive, targeted thermal ablation of intracranial lesions using an MRI‑guided laser fiber probe with real‑time thermography monitoring

FDA‑cleared systems notedPolicy names Visualase and NeuroBlate as FDA‑cleared LITT systems

Drug‑resistant epilepsy (per ASSFN)

ASSFN definitionConsider MRgLITT for drug‑resistant, localization‑related epilepsy when there is failure to respond to, or intolerance of, at least 2 appropriately chosen medications at appropriate doses

Anatomic requirementA well‑defined epileptogenic focus or critical seizure propagation pathway that is accessible by MRgLITT is required

ScopeApplies to disabling, localization‑related epilepsy per ASSFN position statement

Investigational

Policy definitionA treatment, procedure, drug, device, or biological product is investigational if effectiveness has not been clearly tested and it has not been incorporated into standard medical practice

Factors consideredConsideration includes FDA marketing status, need for further studies/clinical trials to determine safety/effectiveness, and consensus evidence from peer‑reviewed literature

Coverage implicationTreatments deemed investigational are excluded from being considered medically necessary until sufficient evidence demonstrates effectiveness

Medically Necessary

Policy definitionMedically necessary services are those a provider, exercising prudent clinical judgment, would provide to prevent, evaluate, diagnose, or treat an illness, injury, disease or its symptoms

Standards requiredServices must be in accordance with nationally accepted standards of medical practice and supported by credible scientific evidence

Clinical appropriateness criteriaServices must be clinically appropriate in type, frequency, extent, level of care, site and duration and not primarily for comfort or convenience