CurrentUnitedHealthcarePolicy CS146KY.11

Electric Tumor Treatment Field Therapy (for Kentucky Only)

Customize your policy alerts

Sign up for UnitedHealthcare Policy CS146KY.11 alerts

Get alerted when Policy CS146KY.11 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Coverage and medical-necessity requirements for electric tumor treatment field therapy for UnitedHealthcare Community Plan members in Kentucky, including criteria for recurrent supratentorial glioblastoma and investigational status for individuals younger than 22 years.

Policy Summary

PayerUnitedHealthcare

PolicyElectric Tumor Treatment Field Therapy (for Kentucky Only)

Policy CodePolicy CS146KY.11

Change TypeAdministrative/supporting-information update

Effective DateOctober 1, 2026

Next Review DateNot specified

Key ActionSubmit the medical-necessity request for review and, when applicable, document that the device will be worn at least 18 hours daily.

SourceLink

POLICY UPDATE CHANGES

The Clinical Evidence and References sections were updated to reflect current information.

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentUnitedHealthcarePolicy CS146KY.11

Electric Tumor Treatment Field Therapy (for Kentucky Only)

Customize your policy alerts

Sign up for UnitedHealthcare Policy CS146KY.11 alerts

Get alerted when Policy CS146KY.11 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerUnitedHealthcare

PolicyElectric Tumor Treatment Field Therapy (for Kentucky Only)

Policy CodePolicy CS146KY.11

Change TypeAdministrative/supporting-information update

Effective DateOctober 1, 2026

Next Review DateNot specified

Key ActionSubmit the medical-necessity request for review and, when applicable, document that the device will be worn at least 18 hours daily.

SourceLink

POLICY UPDATE CHANGES

The Clinical Evidence and References sections were updated to reflect current information.

Kentucky onlyGeographic application

18 hours/dayDaily device wear time

3 monthsInitial approval period

<22 yearsInvestigational age group

Medical Necessity and Coverage Criteria

InterQual medical-necessity pathway

Electric TTF therapy is proven and medically necessary in certain circumstances under the referenced InterQual criteria.

InterQual pathway: Medical necessity may be determined using InterQual CP: Durable Medical Equipment, Tumor Treatment Field Therapy (TTFT) Devices.

When InterQual criteria cannot determine medical necessity, use the policy-specific criteria below.

Initial therapy for recurrent supratentorial glioblastoma

When medical necessity cannot be determined using the InterQual criteria, initial treatment of radiologically confirmed recurrence of glioblastoma in the supratentorial region is covered when ALL of the following are met.

Initial treatment of recurrent supratentorial glioblastoma

Performance status: The individual has KPS ≥60 or ECOG Performance Status ≤2.KPS ≥60 or ECOG ≤2
Either performance-status measure satisfies this element.

Individuals younger than 22 years

Therapy for individuals younger than 22 years is not established as medically necessary.

Age-based investigational status: Electric tumor treatment field therapy for individuals less than age 22 years is experimental or investigational due to lack of FDA-approved indications.Age <22 years

This is an experimental or investigational status rather than a covered criterion.

ASCO/SNO newly diagnosed glioblastoma

ASCO/SNO recommendation

Newly diagnosed supratentorial glioblastoma: Alternating electric field therapy may be added to adjuvant temozolomide in adults with newly diagnosed supratentorial glioblastoma that is IDH-wildtype and CNS WHO grade 4 after completion of chemoradiation therapy.

Evidence quality: moderate; strength of recommendation: weak; benefits outweigh harms.

NCCN newly diagnosed glioblastoma

NCCN category 1 recommendation

Newly diagnosed glioblastoma with good performance status: Use standard brain radiation therapy with concurrent temozolomide followed by adjuvant temozolomide plus alternating electric field therapy in patients with good performance status, including those with either methylated or unmethylated/indeterminate MGMT promoter status, when maximal safe resection was not feasible.KPS ≥60

Alternating electric field therapy is an option only for supratentorial disease.

NCCN age- and performance-status considerations

NCCN treatment considerations

Newly diagnosed glioblastoma treatment option: For patients 70 years of age or younger with newly diagnosed glioblastoma and good performance status, standard brain radiation therapy plus concurrent and adjuvant temozolomide may be given with or without alternating electric field therapy, regardless of MGMT methylation status.Age ≤70 years; good performance status

NCCN identifies this as a category 1 treatment recommendation.

Older adult seeking aggressive treatment: For patients older than 70 years with newly diagnosed glioblastoma, good performance status, and MGMT-unmethylated or indeterminate tumors, standard brain radiation therapy plus concurrent and adjuvant temozolomide with alternating electric field therapy is a reasonable option for those who wish to be treated aggressively.Age >70 years; good performance status

Hypofractionated brain radiation with concurrent and adjuvant temozolomide is preferred in this setting.

NCCN recurrent glioblastoma

NCCN recurrent disease recommendation

Recurrent glioblastoma: Alternating electric treatment fields may be considered for diffuse, multifocal, or local recurrent glioblastoma.

NCCN category 2B; the panel is divided because of limited clear efficacy data.

NICE positions on TTFields

NICE recommendation

Newly diagnosed grade IV glioma: Do not offer TTFields as part of management of newly diagnosed grade IV glioma (glioblastoma) following surgery or when surgery is not possible or has been declined.

NICE recommendation; this is an external guideline position, not an explicit payer coverage determination.

Recurrent high-grade glioma: Do not offer tumor-treating fields as part of management of recurrent high-grade glioma.

NICE recommendation; this is an external guideline position, not an explicit payer coverage determination.

Electric tumor treatment field therapy for individuals younger than 22 years is considered experimental or investigational because FDA-approved indications are lacking.

EANO/ESMO advises against continuing treatment beyond confirmed progression on that same treatment, including bevacizumab and tumor-treating fields, because clinical benefit has not been established.

NICE recommends not offering TTFields as part of management for newly diagnosed grade IV glioma (glioblastoma) following surgery, when surgery is not possible, or when surgery has been declined. NICE also recommends not offering tumor-treating fields for recurrent high-grade glioma.

FDA approval alone is not a basis for coverage. Coverage still depends on the applicable policy requirements and medical-necessity criteria.

Coding and Authorization Parameters

HCPCS CodesHCPCS

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.
E0767	Intrabuccal, systemic delivery of amplitude-modulated, radiofrequency electromagnetic field device, for cancer treatment, includes all accessories.

Karnofsky Performance Status

Minimum qualifying scoreKarnofsky Performance Status (KPS) ≥ 60

Applicable conditionInitial treatment of radiologically confirmed recurrent supratentorial glioblastoma after initial chemotherapy

Alternative performance measureECOG Performance Status ≤ 2 may satisfy the performance-status criterion

ECOG Performance Status

Maximum qualifying scoreECOG Performance Status ≤ 2

Applicable conditionInitial treatment of radiologically confirmed recurrent supratentorial glioblastoma after initial chemotherapy

Provider Submission and Review Requirements

Prior Authorization

Prior Authorization and Initial Approval

Prior authorization and medical-necessity review are required before initial treatment. When InterQual® criteria cannot determine medical necessity, submit the request for radiologically confirmed recurrent glioblastoma (rGBM) in the supratentorial region; when all applicable criteria are met, UnitedHealthcare will approve an initial 3 months of electric TTF therapy.

Refer to InterQual® CP: Durable Medical Equipment, Tumor Treatment Field Therapy (TTFT) Devices for medical-necessity criteria.
Use an FDA-approved device according to its FDA-labeled indications, contraindications, warnings, and precautions.

Documentation Required

Medical-Record Support Required

The medical record must fully support the medical necessity of the requested electric TTF therapy. Records must be legible, maintained in the patient's medical record, and made available upon request; documentation may be required for review but does not guarantee coverage.

Therapy Background

Electric tumor treatment field therapy, also called tumor-treating fields or TTFields, uses low-intensity, intermediate-frequency electric fields to disrupt cell division and potentially destroy proliferating tumor cells. The therapy is delivered through a portable device with scalp-mounted transducer arrays and generally requires prolonged daily wear with periodic array replacement.

Definitions and Abbreviations

Eastern Cooperative Oncology Group (ECOG) Scale of Performance Status

PurposeA standard measure of how disease affects functioning, self-care, daily activity, and physical ability

Scoring rangeScores range from 0 to 5

Qualifying policy thresholdECOG Performance Status ≤ 2; a score of 2 indicates the individual is ambulatory and capable of self-care but unable to work

Karnofsky Performance Status (KPS)

PurposeA standard measure of a cancer patient's ability to perform ordinary tasks and daily activities

Scoring rangeScores range from 0 to 100, with higher scores indicating better functional ability

Treatment-Line Context

Salvage line of therapy

Salvage therapy after initial chemotherapy for recurrent disease.

Recurrent disease after initial chemotherapy: Initial treatment of radiologically confirmed recurrent supratentorial glioblastoma is addressed after initial chemotherapy, using an FDA-approved device according to labeled requirements and the policy's additional criteria.

The policy authorizes an initial 3 months when all criteria are met.

First-line therapy

First-line treatment for newly diagnosed disease.

Adjuvant treatment for newly diagnosed disease: TTFields may be added to adjuvant temozolomide after completion of chemoradiation therapy for newly diagnosed supratentorial glioblastoma; NCCN describes standard radiation therapy with concurrent and adjuvant temozolomide plus alternating electric field therapy for selected patients with good performance status.

Salvage line of therapy

Biomarker and Molecular Status

PTEN mutation

Coverage requirementA PTEN mutation is not required by the coverage criteria

Evidence contextRetrospective evidence reported a possible association between PTEN-mutant recurrent glioblastoma and benefit from TTFields

Reported findingAmong TTFields-treated individuals, median post-progression survival was 22.2 months for PTEN-mutant versus 11.6 months for PTEN-wildtype recurrent glioblastoma

MGMT promoter methylation

Coverage requirementMGMT promoter methylation is not required by the coverage criteria

Evidence contextTreatment combinations were evaluated in newly diagnosed glioblastoma by MGMT promoter methylation status

Covered Treatment Regimens

Regimen	Applicable indication and requirements	Coverage
FDA-approved electric tumor treatment field device used as the only treatment	Initial treatment of radiologically confirmed recurrent glioblastoma in the supratentorial region after initial chemotherapy; device must be used according to FDA-labeled indications, contraindications, warnings, and precautions. KPS must be ≥60 or ECOG Performance Status ≤2, and the individual must be counseled to wear the device at least 18 hours daily.	Covered

Regimen	Applicable indication and requirements	Coverage
TTFields plus maintenance temozolomide	Newly diagnosed glioblastoma after tumor resection or biopsy and completion of concomitant radiochemotherapy.	Covered

Regimen	Applicable indication and requirements	Coverage
Standard brain radiation therapy plus concurrent and adjuvant temozolomide, with or without alternating electric field therapy	Newly diagnosed glioblastoma in patients with good performance status. NCCN describes this as a category 1 option, including patients aged 70 years or younger regardless of MGMT promoter methylation status; alternating electric field therapy is an option only for supratentorial disease.	Covered

Regimen	Applicable indication and requirements	Coverage
Alternating electric treatment fields	Diffuse, multifocal, or local recurrent glioblastoma. NCCN classifies this as category 2B; the panel is divided because of limited clear efficacy data.	Experimental or investigational

Regimen	Applicable indication and requirements	Coverage
Optune with temozolomide and concomitant standard-of-care chemotherapy	Newly diagnosed supratentorial glioblastoma after maximal debulking surgery and completion of radiation therapy, together with concomitant standard-of-care chemotherapy.	Covered

Policy Summary

PayerUnitedHealthcare

PolicyElectric Tumor Treatment Field Therapy (for Kentucky Only)

Policy CodePolicy CS146KY.11

Change TypeAdministrative/supporting-information update

Effective DateOctober 1, 2026

Next Review DateNot specified

Key ActionSubmit the medical-necessity request for review and, when applicable, document that the device will be worn at least 18 hours daily.

SourceLink

On This Page

Alternative performance measure

KPS ≥ 60 may satisfy the performance-status criterion

Daily device wear time

Minimum daily useAt least 18 hours daily

Counseling requirementThe individual must be counseled that the device must be worn at least 18 hours daily

Treatment descriptionThe portable device is used for at least 18 continuous hours per day

Initial approval duration

Initial approval period3 months

Applicable diseaseRecurrent glioblastoma (rGBM) meeting the policy criteria

Approval conditionAll specified criteria must be met before the initial 3-month approval is granted

Include relevant medical history.
Include physical examination findings.
Include results of pertinent diagnostic tests or procedures.

Documentation Required

Clinical Criteria Documentation

For an rGBM request when InterQual® criteria cannot determine medical necessity, document radiologically confirmed recurrence in the supratentorial region and each applicable clinical requirement for initial treatment.

The FDA-approved device is used after initial chemotherapy and according to FDA-labeled indications, contraindications, warnings, and precautions.
The device is used as the only treatment.
The individual has a KPS score of ≥ 60 or an ECOG Performance Status of ≤ 2.
The individual has been counseled that the device must be worn at least 18 hours daily.

Denial Risk

Failure to Meet Clinical Criteria

Coverage may not be approved when the request does not establish the required clinical criteria for initial rGBM treatment. Failure to document radiologically confirmed supratentorial recurrence, exclusive use of the device, the required functional-status threshold, or counseling regarding daily wear may prevent approval.

The initial approval period is 3 months only when all applicable criteria are met.
Medical records must support the submitted clinical facts and medical necessity.

Denial Risk

Individuals Younger Than 22 Years

Electric TTF therapy for individuals younger than 22 years is considered experimental or investigational because of a lack of FDA-approved indications. Providers should not represent the therapy as covered under this policy for this age group.

Verify the individual's age before submitting a request.
The experimental or investigational designation is based on the lack of FDA-approved indications for individuals younger than 22 years.

Note

FDA Approval Alone Is Insufficient

FDA approval of a device alone does not establish coverage. Coverage remains subject to the applicable benefit, policy requirements, and medical-necessity criteria.

The Optune Treatment Kit, formerly the NovoTTF-100A System, was FDA-approved for specified adult glioblastoma indications; those approvals do not independently guarantee coverage.
Submit documentation showing that the requested use meets the policy's coverage criteria, not merely that the device has FDA approval.

Qualifying policy threshold

KPS ≥ 60; a score of 60 means occasional assistance is required but most personal needs can be managed

Supratentorial

Anatomical meaningThe upper portion of the brain

Included structuresThe cerebrum, ventricles, choroid plexus, hypothalamus, pineal gland, pituitary gland, and optic nerve

Policy relevanceThe recurrent glioblastoma coverage criterion applies to disease in the supratentorial region of the brain

Electric tumor treatment field (TTF) therapy

Alternate namesTumor-treating fields, TTFields, and ETTFs

Therapy basisLow-intensity, intermediate-frequency electric fields disrupt cell division and may destroy proliferating cells in brain tumors

Frequency described in the policy100 to 300 kHz

ndGBM

AbbreviationndGBM

MeaningNewly diagnosed glioblastoma

Common treatment contextInitial treatment generally consists of debulking surgery when feasible, followed by radiation and chemotherapy

rGBM

AbbreviationrGBM

MeaningRecurrent glioblastoma

Policy contextThe policy addresses radiologically confirmed recurrence in the supratentorial region after initial chemotherapy

TTFields

AbbreviationTTFields

MeaningAlternating electric field therapy

Alternate terminologyTumor-treating fields; the policy also uses electric tumor treatment field therapy and ETTFs

Salvage treatment at recurrence.

Treatment at recurrence: TTFields may be considered by NCCN for diffuse, multifocal, or local recurrent glioblastoma, although the recommendation is category 2B and efficacy data are unclear. NICE recommends against TTFields for recurrent high-grade glioma, and EANO/ESMO advises against continuation beyond confirmed progression on the same treatment.

Guideline positions conflict.

Salvage line of therapy

Salvage indication for recurrent or progressive disease.

Recurrent or progressive glioblastoma indication: Adults aged 22 years or older with glioblastoma that recurs or progresses after chemotherapy and radiation therapy.Age ≥22 years

FDA indication; FDA approval alone is not a basis for coverage.

First-line therapy

First-line indication for newly diagnosed supratentorial disease.

Newly diagnosed supratentorial glioblastoma indication: Adults with newly diagnosed supratentorial glioblastoma following maximal debulking surgery and completion of radiation therapy, together with concomitant standard-of-care chemotherapy with temozolomide.None stated

Supplemental FDA indication; FDA approval alone is not a basis for coverage.

Evidence findingTTField combination therapy was associated with increased survival regardless of MGMT promoter methylation status in the reviewed evidence

IDH

Required status in the ASCO/SNO recommendationIDH-wildtype

Disease contextNewly diagnosed supratentorial glioblastoma

Treatment contextAlternating electric field therapy may be added to adjuvant temozolomide after completion of chemoradiation therapy

MGMT promoter methylation

MethylatedNCCN includes patients with methylated MGMT promoter status among those eligible for the specified newly diagnosed glioblastoma treatment recommendation

UnmethylatedNCCN includes patients with unmethylated MGMT promoter status among those eligible for the specified treatment recommendation

IndeterminateNCCN also includes patients with indeterminate MGMT promoter status