Tumor Treating Field (TTF) therapy for glioblastoma multiforme
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Defines medical necessity and utilization management guidance for Tumor Treating Field (TTF) electrical therapy in individuals with histologically confirmed glioblastoma multiforme; applies to Commercial and Medicare lines of business under Network Health.
No material clinical or coverage changes in this revision.
Coverage Criteria
Coverage criteria (aligned with LCD and MCG)
Covered when consistent with referenced guideline and CMS LCD criteria:
See CMS LCD L34823 and MCG A0930 for specific criteria and continuity of coverage
Coverage determinations in this policy are subject to the terms of the member's benefit plan and applicable law. Contract language and state or federal laws take precedence over the medical policy. Network Health coverage documents (for example, Certificates of Coverage, Evidence of Coverage, and Summary Plan Descriptions) define the contractual terms for each line of business and will be consulted first to determine member eligibility; coverage may differ by benefit plan. For Medicare members, applicable CMS statements including NCDs and LCDs likewise govern coverage determinations.
An annual review was completed for this policy and no changes were made to expand or restrict medical necessity determinations. The review included an update of references and CPT code verification. Specific conditions determined to be not medically necessary should continue to follow the referenced CMS LCD L34823 and MCG guidance where applicable.
Coding and Related References
| No codes listed |
| No codes listed |
Provider Actions and Operational Notes
Prior authorization and CPT code verification required
Prior authorization requests must follow this medical policy and the referenced external guidance. Verify and submit applicable CPT/HCPCS procedure codes as part of the prior authorization; CPT code verification was completed during the policy's annual review. Prior authorization decisions are aligned with CMS LCD L34823 and MCG Ambulatory Care guidance.
- Prior authorization guided by this medical policy
- Align authorization with CMS LCD L34823 and MCG Ambulatory Care A0930 guidance
- Include CPT/HCPCS code verification with the request
Follow guideline-informed sequencing and line-of-therapy guidance
Follow the sequencing and line-of-therapy recommendations in the cited guidelines when determining initial and continued use of TTF. The policy references CMS LCD L34823 and MCG guidance, which inform comparisons (e.g., to temozolomide in newly diagnosed GBM) and authorization decisions across first- and second-line contexts.
- Adhere to guideline-recommended sequencing and line-of-therapy guidance in CMS LCD L34823 and MCG A0930
- Use referenced guidance when comparing TTF to chemotherapy (e.g., temozolomide) for authorization
Required documentation: histology, daily use, and minimum duration
Document histologic confirmation of glioblastoma multiforme and a treatment plan that specifies Tumor Treating Field (TTF) usage and duration. The plan should indicate target daily device use (approximately 18 hours/day) and the planned minimum treatment span (at least 4 weeks), and include evidence that the clinical indication is consistent with CMS LCD L34823 and relevant MCG guidance.
- Histologic confirmation of GBM must be in the record
- Treatment plan must state TTF intended use, target ~18 hours/day, and planned minimum duration of ≥4 weeks
- Include documentation showing indication meets CMS LCD L34823 and MCG criteria
Administrative review: no change to policy intention or utilization
No substantive changes were made to the policy's intention or utilization during the review; an annual review was performed and references (and CPT verification) were updated as needed. Providers should expect continuity in policy application following this review.
- Annual review performed; references updated as needed
- Policy intention and utilization remain unchanged
Background
Tumor Treating Field (TTF) therapy is a portable electrical therapy that delivers alternating low‑intensity, intermediate‑frequency electric fields to the scalp via adhesive transducer arrays. The applied fields are intended to disrupt mitosis in dividing tumor cells, thereby inhibiting tumor growth. Typical protocols referenced in this policy specify approximately 18 hours per day of device use and a minimum continuous treatment span of 4 weeks to assess clinical response.
Definitions
Line of Therapy (Initial and Subsequent Use)
first-line | second-line
See referenced guidelines for line-specific requirements and sequencing
Covered Regimens and Indications
| Regimen | Indication | Coverage status |
|---|---|---|
| Tumor Treating Field therapy (device with transducer arrays, continuous use ~18 hours/day) | Newly diagnosed glioblastoma multiforme when used in conjunction with standard therapy (evidence shows increased overall survival and progression‑free survival versus temozolomide alone) | Covered |
| Regimen | Indication | Coverage status |
|---|---|---|
| Tumor Treating Field therapy (device with transducer arrays) | Recurrent glioblastoma multiforme where evidence shows outcomes at least equivalent to chemotherapy (overall survival and progression‑free survival comparable) | Covered |
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