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    v1.0.30
    OpenPayerPolicy UpdatesHematology/OncologyPremera TACE Liver Tumor Coverage Update | OpenPay…
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    CurrentPremera Blue Cross of WashingtonPolicy N/A

    Transcatheter Arterial Chemoembolization for Liver Tumors

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    This policy governs when transcatheter hepatic arterial chemoembolization may be considered medically necessary or investigational for primary liver cancer and hepatic metastases.

    Policy Summary
    PayerPremera Blue Cross of Washington
    PolicyTranscatheter Arterial Chemoembolization for Liver Tumors
    Policy CodePolicy N/A
    Change TypeAnnual reviewno material clinical or coverage changes
    Effective DateOct 1, 2026
    Last ReviewOct 1, 2026
    Next Review DateN/A
    Key ActionSubmit office visit notes documenting the applicable medical-necessity criteria, including tumor characteristics, portal vein status, Child-Pugh class, symptoms, treatment response, and surgical candidacy.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    4Medically necessary clinical indications
    4Investigational use situations
    2CPT codes listed
    5Child-Pugh classification parameters
    5–15Child-Pugh total score range

    Medical Necessity and Investigational Use

    Medical Necessity

    Transcatheter hepatic arterial chemoembolization may be considered medically necessary when ANY ONE of the following conditions is met:

    ANY of the following

    • Hepatocellular cancer

      • Hepatocellular cancer is unresectable but confined to the liver.
      • The hepatocellular cancer is not associated with portal vein thrombosis.
      • Liver function is not characterized as Child-Pugh class C.

        See Related Information for Child-Pugh Classification.

    • Bridge to liver transplant

      • The individual has hepatocellular cancer and treatment is intended to prevent further tumor growth and maintain candidacy for liver transplantation.

      • Tumor burden

        • A single tumor is present.< 5 cm
        • No more than 3 tumors are present, with each tumor meeting the size criterion.Each < 3 cm
      • Absence of extrahepatic disease or vascular invasion.
      • Child-Pugh class A or B.

        See Related Information for Child-Pugh Classification.

    • Symptomatic metastatic neuroendocrine tumor

      • Liver metastases from a metastatic neuroendocrine tumor are present.
      • Symptoms persist despite systemic therapy.
      • The individual is not a candidate for surgical resection.
    • Liver-dominant metastatic uveal melanoma.

    Investigational Indications

    Transcatheter hepatic arterial chemoembolization is considered investigational when ANY ONE of the following conditions applies:

    ANY of the following

    • Use as neoadjuvant or adjuvant therapy in resectable hepatocellular cancer.
    • Use in combination with radiofrequency ablation (RFA) to treat resectable or unresectable hepatocellular carcinoma.
    • Treatment of unresectable cholangiocarcinoma.
    • Treatment of recurrent hepatocellular carcinoma or hepatocellular cancer that does not meet the medical-necessity criteria above.

    Treatment of hepatocellular tumors prior to liver transplantation is considered investigational, except when the bridge-to-transplant medical-necessity criteria are met. The exception applies when the intent is to prevent further tumor growth and maintain the individual's candidacy for liver transplantation, with a single tumor less than 5 cm or no more than 3 tumors each less than 3 cm, absence of extrahepatic disease or vascular invasion, and Child-Pugh class A or B.

    Treatment of liver metastases from tumors outside the covered symptomatic metastatic neuroendocrine tumor indication is considered investigational. This includes treatment of liver metastases from other tumor types when the medical-necessity criteria for symptomatic metastatic neuroendocrine tumor are not met.

    Codes and Clinical Classification

    CPT CodesCPT
    37243Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction.
    75894Transcatheter therapy, embolization, any method, radiological supervision and interpretation
    Child-Pugh classification scoring parameters
    AscitesNone = 1 point; suppressed with medications = 2 points; refractory = 3 points.
    Bilirubin<34 µM = 1 point; 34–50 µM = 2 points; >50 µM = 3 points.
    Albumin>35 g/L = 1 point; 28–35 g/L = 2 points; <28 g/L = 3 points.
    INR<1.7 = 1 point; 1.7–2.2 = 2 points; >2.2 = 3 points.
    EncephalopathyGrade 0 = 1 point; Grade 1–2 or suppressed with medications = 2 points; Grade 3–4 or refractory = 3 points.
    Child-Pugh classes
    Class A5–6 points; well-compensated liver disease.
    Class B7–9 points; significant functional impairment.
    Class C10–15 points; decompensated liver function.

    Documentation and Coverage Decision Risks

    Documentation Required

    Medical Records and Office Notes Required

    Submit medical records demonstrating that the applicable medical-necessity criteria are met. Documentation should include office visit notes with the relevant history and physical examination for the condition being treated, along with clinical support for medical necessity.

    • Unresectable primary liver cancer confined to the liver without portal vein thrombosis or narrowing.
    • Bridge to liver transplantation: a single tumor less than 5 cm, or no more than 3 tumors each less than 3 cm; no extrahepatic disease or vascular invasion; and Child-Pugh class A or B.
    • Symptomatic neuroendocrine liver metastases that persist despite systemic therapy when the individual is not a candidate for surgical resection.
    • Liver-dominant metastatic uveal melanoma.
    Denial Risk

    Investigational Uses

    Transcatheter hepatic arterial chemoembolization (TACE) is considered investigational for the uses listed below and may not be covered under this policy.

    • Neoadjuvant or adjuvant therapy for resectable hepatocellular cancer.
    • Combination treatment with radiofrequency ablation (RFA) for resectable or unresectable hepatocellular carcinoma.
    • Treatment of unresectable cholangiocarcinoma.
    • Treatment of liver metastases from any other primary tumor, or treatment of hepatocellular cancer that does not meet the medical-necessity criteria, including recurrent hepatocellular carcinoma.
    • Treatment of hepatocellular tumors before liver transplantation, except when the stated bridge-to-transplant criteria are met.
    Note

    Insufficient Evidence for Most Non-Uveal Hepatic Metastases

    Evidence is insufficient to determine that TACE improves net health outcomes for unresectable hepatic metastases from primary tumors other than the covered uveal melanoma and neuroendocrine tumor indications. For colorectal cancer, studies show variable disease stabilization and some response or progression-free-survival findings, but a prolonged survival benefit over systemic chemotherapy remains uncertain; evidence for other cancers, including breast cancer, is extremely limited.

    • Applies to unresectable hepatic metastases from other primary tumors, including colorectal and breast cancer.
    • Studies are limited by small populations, variable individual-selection criteria, and differing treatment regimens.
    • Insufficient evidence supports a conclusion of improved overall survival, disease-specific survival, quality of life, or treatment-related morbidity and mortality.
    Denial Risk

    Criteria Not Met

    TACE is considered investigational when the policy medical-necessity criteria are not met, including treatment of hepatocellular cancer outside the specified eligible indications.

    • Verify that the diagnosis, disease extent, liver function, transplant-bridging criteria, and other applicable requirements are documented before submission.
    • Failure to satisfy or document the criteria creates a coverage denial risk.

    Clinical Background and Evidence

    Transcatheter arterial chemoembolization (TACE) is a minimally invasive, liver-directed procedure. A catheter is advanced through the arterial system into the hepatic artery to deliver concentrated chemotherapy to the tumor-bearing region, followed by infusion of embolic material that restricts tumor blood flow. This produces ischemia and necrosis while prolonging local drug retention.

    Key Terms

    Child-Pugh classification
    PurposeThe Child-Pugh classification estimates the severity of liver disease.
    Component measuresThe classification uses ascites, bilirubin, albumin, INR, and encephalopathy, with each measure assigned 1, 2, or 3 points.
    Severity classesTotal scores correspond to Class A (5–6 points), Class B (7–9 points), or Class C (10–15 points).
    Clinical interpretationClass A indicates well-compensated disease, Class B indicates significant functional impairment, and Class C indicates decompensated liver function.
    Transarterial chemoembolization (TACE)
    ProcedureTransarterial chemoembolization (TACE) is a liver-directed procedure for treating hepatic tumors.
    Chemotherapy deliveryChemotherapy is delivered through the arterial system directly to the tumor-bearing liver region.
    EmbolizationThe tumor-feeding arterial supply is then embolized to restrict blood flow and prolong local drug retention; conventional TACE and drug-eluting bead TACE are discussed.
    NCT
    MeaningNCT means national clinical trial.
    Use in this policyAn NCT number is the national clinical trial registry identifier used to identify ongoing and unpublished studies summarized in the clinical-trial table.
    ExamplesExamples include NCT06909708, NCT06715072, NCT06353126, NCT04143191, NCT04912258, NCT02724540, and NCT02936388.
    Policy Summary
    PayerPremera Blue Cross of Washington
    PolicyTranscatheter Arterial Chemoembolization for Liver Tumors
    Policy CodePolicy N/A
    Change TypeAnnual reviewno material clinical or coverage changes
    Effective DateOct 1, 2026
    Last ReviewOct 1, 2026
    Next Review DateN/A
    Key ActionSubmit office visit notes documenting the applicable medical-necessity criteria, including tumor characteristics, portal vein status, Child-Pugh class, symptoms, treatment response, and surgical candidacy.
    SourceLink
    On This Page
    Medical Necessity and Investigational UseCodes and Clinical ClassificationDocumentation and Coverage Decision RisksClinical Background and EvidenceKey Terms

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