CurrentUnitedHealthcare Community PlanPolicy CS146KS.04

Electric Tumor Treatment Field Therapy (for Kansas Only)

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This UnitedHealthcare Community Plan medical policy governs coverage of electric tumor treatment field therapy for Kansas Medicaid members, including medical necessity, documentation, coding, and review criteria.

Policy Summary

PayerUnitedHealthcare Community Plan

PolicyElectric Tumor Treatment Field Therapy (for Kansas Only)

Policy CodePolicy CS146KS.04

Change TypeAdministrative and evidentiary update

Effective DateOctober 1, 2026

Next Review DateN/A

Key ActionSubmit medical necessity documentation and obtain prior authorization for electric TTF therapy.

SourceLink

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CurrentUnitedHealthcare Community PlanPolicy CS146KS.04

Electric Tumor Treatment Field Therapy (for Kansas Only)

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Sign up for UnitedHealthcare Policy CS146KS.04 alerts

Get alerted when Policy CS146KS.04 changes without checking for updates manually.

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Policy Summary

PayerUnitedHealthcare Community Plan

PolicyElectric Tumor Treatment Field Therapy (for Kansas Only)

Policy CodePolicy CS146KS.04

Change TypeAdministrative and evidentiary update

Effective DateOctober 1, 2026

Next Review DateN/A

Key ActionSubmit medical necessity documentation and obtain prior authorization for electric TTF therapy.

SourceLink

POLICY UPDATE CHANGES

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

Kansas onlyPolicy application

18 hours/dayMinimum device wear time

3 monthsInitial approval period

<22 yearsExperimental or investigational age group

Coverage Criteria

InterQual TTFT Device Criteria

Covered when medical necessity criteria are met.

InterQual medical necessity pathway: Electric TTF therapy is considered proven and medically necessary in certain circumstances when the applicable InterQual CP: Durable Medical Equipment, Tumor Treatment Field Therapy (TTFT) Devices criteria are met.

The policy directs reviewers to the referenced InterQual criteria.

Initial Therapy for Recurrent Supratentorial Glioblastoma

When medical necessity cannot be determined using the InterQual criteria, covered initial treatment requires all of the following:

Initial treatment of recurrent supratentorial glioblastoma

FDA-approved device and labeled use: Use a U.S. FDA-approved device to generate electric tumor treatment fields after initial chemotherapy, according to FDA-labeled indications, contraindications, warnings, and precautions.
Only treatment: The device is used as the only treatment.
Performance status
- KPS threshold: Karnofsky Performance Status is at least 60.≥ 60
- ECOG threshold: Eastern Cooperative Oncology Group Scale of Performance Status is 2 or less.≤ 2
Wear-time counseling: The individual has been counseled that the electric TTF device must be worn for at least 18 hours daily.≥ 18 hours daily

Individuals Younger Than 22 Years

Not covered as proven and medically necessary.

Age-related investigational status: Electric TTF therapy for individuals younger than 22 years is experimental or investigational due to lack of FDA-approved indications.Age < 22 years

Newly Diagnosed Glioblastoma

NCCN treatment context for newly diagnosed glioblastoma.

Patient subgroup and treatment options: For patients with glioblastoma who are 70 years of age or younger and have good performance status, NCCN lists clinical trial participation, radiation therapy plus concurrent and adjuvant temozolomide with alternating electric field therapy, or radiation therapy plus concurrent and adjuvant temozolomide; options vary by MGMT methylation status.Age ≤70 years; KPS ≥60

Alternating electric field therapy is described as a preferred category 1 option with radiation therapy and temozolomide in the cited NCCN recommendations.

Older adults with good performance status: For patients older than 70 years with glioblastoma and KPS ≥60, NCCN lists age- and MGMT-dependent options including hypofractionated radiation therapy with concurrent and adjuvant temozolomide or standard radiation therapy with concurrent and adjuvant temozolomide plus alternating electric field therapy.Age >70 years; KPS ≥60

The cited recommendations distinguish methylated, unmethylated, and indeterminate MGMT status.

Recurrent or Progressive Glioblastoma

NCCN treatment context for recurrent or progressive disease.

Recurrent or progressive glioblastoma: For recurrent or progressive glioblastoma, NCCN recommends considering clinical trials, systemic therapy, surgery when appropriate, reirradiation, alternating electric field therapy for glioblastoma, or palliative or best supportive care depending on disease characteristics and performance status.KPS ≥60 for specified grade 3 and 4 glioma subgroups

Alternating electric field therapy is listed as a category 2B option for glioblastoma; poor performance status may favor palliative or best supportive care.

NICE Position

NICE recommendations.

NICE position on TTFields: NICE states not to offer TTFields as part of management of newly diagnosed grade IV glioma or recurrent high-grade glioma.Newly diagnosed grade IV glioma or recurrent high-grade glioma

This is a cited external guideline recommendation, not an explicit UnitedHealthcare coverage determination in this excerpt.

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

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

Coding and Operational Parameters

Applicable 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

FDA Device Product CodeHCPCS

NZK	Product code identified for supplemental FDA approvals for the Optune device

Karnofsky Performance Status

Coverage thresholdKarnofsky Performance Status (KPS) score of at least 60

Applicable settingInitial treatment of radiologically confirmed recurrent supratentorial glioblastoma when InterQual criteria cannot determine medical necessity

Alternative performance criterionMay be met instead with an ECOG Scale of Performance Status of 2 or less

ECOG Scale of Performance Status

Coverage thresholdECOG Scale of Performance Status of 2 or less

DefinitionStandard measure of how disease affects self-care, daily activity, and physical ability

Provider and Documentation Requirements

Prior Authorization

Prior Authorization and Medical Necessity Review

Obtain prior authorization and submit the request for InterQual® CP: Durable Medical Equipment, Tumor Treatment Field Therapy (TTFT) Devices review. When medical necessity cannot be determined under InterQual® criteria, the recurrent glioblastoma criteria in this policy apply.

Note

Three-Month Initial Approval

When all required criteria for initial treatment of radiologically confirmed recurrent glioblastoma in the supratentorial region are met, UnitedHealthcare will approve an initial three months of electric TTF therapy.

FDA-approved TTF device used according to labeled indications, contraindications, warnings, and precautions
TTF device used as the only treatment
KPS score ≥ 60 or ECOG performance status ≤ 2
Member counseled to wear the device at least 18 hours daily

Therapy Line Context

Salvage-Line Therapy

Salvage-line therapy context for recurrent disease.

Initial treatment for recurrent disease: Radiologically confirmed recurrence of glioblastoma in the supratentorial region after initial chemotherapy, using an FDA-approved device according to labeled requirements, as the only treatment, with KPS ≥60 or ECOG ≤2 and counseling for device wear of at least 18 hours daily.Initial treatment; 3-month approval

Applies when medical necessity cannot be determined using the InterQual criteria.

First-Line Therapy

First-line therapy context for newly diagnosed glioblastoma.

Newly diagnosed glioblastoma adjunctive therapy: TTFields may be added to maintenance or adjuvant temozolomide after completion of standard radiochemotherapy in newly diagnosed glioblastoma; NCCN identifies adjuvant temozolomide plus alternating electric field therapy as a preferred category 1 option in specified patients with supratentorial disease.

Biomarker and Molecular Requirements

IDH

Required findingIDH-wild-type (IDH-WT)

Population describedRecurrent glioblastoma (rGBM) treated with TTFields at first recurrence

Evidence contextThe IDH-WT finding describes the recurrent glioblastoma population studied; it is not stated as a standalone coverage requirement in this evidence discussion

PTEN

PTEN-mutant tumorsIn a retrospective analysis, TTFields-treated PTEN-mutant rGBM had longer median postprogression survival

PTEN-mutant resultMedian postprogression survival was 22.2 months with TTFields versus 9.3 months without TTFields in the PTEN-mutant group

Covered and Referenced Regimens

Regimen	Indication	Coverage
FDA-approved electric tumor treatment field device used as the only treatment	Initial treatment of radiologically confirmed recurrent supratentorial glioblastoma after initial chemotherapy; device must be used according to FDA-labeled indications, contraindications, warnings, and precautions	Covered when all specified criteria are met

Regimen	Indication	Coverage
Electric tumor treatment field therapy	Individuals younger than 22 years	Experimental or investigational; not covered as proven and medically necessary

Regimen	Indication	Coverage
Radiation therapy plus concurrent temozolomide, followed by adjuvant temozolomide plus alternating electric field therapy	Newly diagnosed glioblastoma in selected patients, including patients with good performance status (KPS ≥60); NCCN options vary by age and MGMT promoter methylation status	Covered regimen option

Regimen	Indication	Coverage
Alternating electric field therapy considered with clinical trials, systemic therapy, surgery, reirradiation, or palliative/best supportive care	Recurrent or progressive glioblastoma; options depend on disease characteristics, resectability, and performance status	Covered as a consideration for glioblastoma

Regimen	Indication	Coverage
TTFields	Newly diagnosed grade IV glioma or recurrent high-grade glioma under NICE guidance	Do not offer

Therapy Background

Electric tumor treatment field therapy, also called tumor-treating fields or TTFields, uses low-intensity, intermediate-frequency alternating electric fields—described in the policy as 100 to 300 kHz—to disrupt cell division and potentially destroy proliferating tumor cells. The therapy is delivered noninvasively through transducer arrays placed on the scalp and generally requires prolonged daily device use, array replacement, scalp preparation, and patient or caregiver training for device operation.

Definitions

Eastern Cooperative Oncology Group (ECOG) Scale of Performance Status

DefinitionA standard measure of how disease affects a person's functioning, including self-care, daily activity, and physical ability

Score rangeScores range from 0 (fully active) to 5 (dead)

Coverage-relevant scoreA score of 2 means the individual is ambulatory and capable of all self-care but unable to carry out work activities

Karnofsky Performance Status (KPS)

DefinitionA standard measure of a patient's ability to perform ordinary tasks and carry out daily activities

Score rangeScores range from 0 to 100; higher scores indicate greater ability to carry out daily activities

Policy Summary

PayerUnitedHealthcare Community Plan

PolicyElectric Tumor Treatment Field Therapy (for Kansas Only)

Policy CodePolicy CS146KS.04

Change TypeAdministrative and evidentiary update

Effective DateOctober 1, 2026

Next Review DateN/A

Key ActionSubmit medical necessity documentation and obtain prior authorization for electric TTF therapy.

SourceLink

On This Page

Score rangeScores range from 0 (fully active) to 5 (dead)

Daily TTF Device Wear

Minimum wear timeAt least 18 hours daily

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

Treatment deliveryTTF treatment is delivered through a portable device and scalp transducer arrays

Initial Approval Duration

Initial approval period3 months

Applicable indicationInitial electric TTF treatment for radiologically confirmed recurrent glioblastoma in the supratentorial region

Approval conditionAll specified fallback criteria for recurrent glioblastoma must be met

Documentation Required

Medical Necessity Records Required

Submit legible medical records that fully support medical necessity for the requested service. Records must be maintained in the patient's medical record and made available upon request.

Relevant medical history
Physical examination findings
Pertinent diagnostic test or procedure results

Documentation Required

Document Recurrent Glioblastoma

For recurrent glioblastoma requests, document radiologically confirmed recurrence in the supratentorial brain and the prior treatment history, including initial chemotherapy, supporting the requested initial TTF therapy.

Radiologic confirmation of recurrent glioblastoma
Documentation of prior treatment, including initial chemotherapy

Documentation Required

Postoperative MRI Documentation

For postoperative documentation, include a postoperative MRI scan with and without contrast performed within 48 hours after surgery to document the extent of tumor debulking, consistent with NCCN guidance.

MRI with and without contrast
Performed within 48 hours after surgery
Documents extent of resection or tumor debulking

Denial Risk

Age Under 22: Experimental or Investigational

Electric TTF therapy for individuals younger than 22 years is considered experimental or investigational because there are no FDA-approved indications for this age group.

Verify the member's age before requesting authorization

Denial Risk

Failure to Meet Medical Necessity Criteria

Requests that do not satisfy the recurrent glioblastoma medical necessity requirements may not be approved. Confirm and document every required criterion before submitting the request to reduce denial risk.

Radiologically confirmed supratentorial recurrent glioblastoma
FDA-approved device used according to labeling
TTF used as the only treatment
KPS ≥ 60 or ECOG ≤ 2
Counseling that the device must be worn at least 18 hours daily

Denial Risk

Insufficient Medical Records

If the submitted records do not support medical necessity, coverage cannot be assured and the request may be denied or unable to be approved. Provide complete, legible documentation and make it available upon request.

Incomplete records may prevent clinical criteria review
Documentation of medical necessity does not itself guarantee coverage

Denial Risk

Do Not Continue Beyond Confirmed Progression

Do not continue TTFields beyond confirmed progression on the same treatment. EANO advises against treatment beyond confirmed progression because the clinical benefit has not been established.

Apply this guidance to TTFields as well as other treatments addressed by the recommendation

After completion of chemoradiation; NCCN performance-status and age stratification applies

ASCO/SNO describes this recommendation as evidence-based with moderate-quality evidence and weak strength of recommendation.

Salvage-Line Therapy

Salvage-line therapy context for recurrent glioblastoma.

Recurrent glioblastoma: Evidence for TTFields in recurrent glioblastoma is mixed; ECRI reported similar overall survival between Optune Gio and best standard-care chemotherapy, while EANO states that treatment beyond confirmed progression on the same treatment, including TTFields, should not be used because clinical benefit has not been established.At recurrence or after confirmed progression

The evidence includes systematic reviews and observational studies and does not establish a definitive preferred recurrent-disease regimen.

First-Line Therapy

First-line therapy context for newly diagnosed glioblastoma.

Newly diagnosed glioblastoma with age, KPS, and MGMT status used to determine NCCN treatment options; alternating electric field therapy may be combined with concurrent and adjuvant temozolomide after radiation therapy.KPS ≥60

Treatment options differ by age and MGMT methylation status.

Salvage-Line Therapy

Salvage-line therapy context for recurrent or progressive disease.

Recurrent or progressive glioblastoma: For recurrent or progressive disease, options include clinical trials, systemic therapy, surgery or reirradiation when appropriate, alternating electric field therapy for glioblastoma, or palliative or best supportive care.KPS ≥60 for specified subgroups

NCCN lists alternating electric field therapy as category 2B for recurrent glioblastoma; NICE recommends not offering TTFields in recurrent high-grade glioma.

PTEN-wild-type tumorsNo postprogression survival benefit was observed in PTEN-wild-type patients receiving TTFields

MGMT Promoter Methylation

MethylatedMGMT promoter methylation status may be used in treatment selection and guideline stratification

UnmethylatedMGMT promoter-unmethylated tumors may derive less benefit from temozolomide; guideline options vary accordingly

IndeterminateIndeterminate MGMT promoter status is a recognized treatment-stratification category

IDH and 1p/19q Status

Molecular profileIDH-wild-type, CNS WHO grade 4, supratentorial glioblastoma

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

Evidence and recommendation strengthEvidence quality is moderate, with a weak strength of recommendation

MGMT Promoter Methylation Status

MethylatedMGMT promoter-methylated status is used to guide treatment recommendations

UnmethylatedMGMT promoter-unmethylated status is used to guide treatment recommendations and may indicate less benefit from temozolomide

IndeterminateMGMT promoter-indeterminate status is included in treatment-stratification recommendations

Applicable Molecular Findings

IDH1/2 mutationIDH1/2-mutant glioma is an applicable recurrent or progressive disease subgroup

1p/19q codeletion1p/19q-codeleted disease is an applicable subgroup, including IDH1/2-mutant oligodendroglioma

H3 mutationH3-mutated high-grade glioma is an applicable recurrent or progressive disease subgroup

Coverage-relevant scoreA KPS of 60 means occasional assistance is required, but most personal needs can be managed

Supratentorial

Anatomic locationThe upper portion of the brain

Principal structureComprises the cerebrum

Included structuresAlso includes the ventricles, choroid plexus, hypothalamus, pituitary gland, pineal gland, and optic nerve

Electric Tumor Treatment Field (TTF) Therapy

Also calledTumor-treating fields, TTFields, or ETTFs

Treatment definitionUses low-intensity, intermediate-frequency electric fields to disrupt cell division

Frequency range100 to 300 kHz