CurrentUnitedHealthcarePolicy CS060KS.02

Transarterial Radioembolization (TARE)/Selective Internal Radiation Therapy (SIRT) for the Treatment of Malignant Cancers of the Liver (for Kansas Only)

Policy governs coverage of yttrium-90 microsphere transarterial radioembolization/selective internal radiation therapy for individuals in Kansas (applies to ages 19 and older for this policy). It references InterQual criteria for medical necessity.

Policy Summary

PayerUnitedHealthcare

PolicyTransarterial Radioembolization (TARE)/Selective Internal Radiation Therapy (SIRT) for the Treatment of Malignant Cancers of the Liver (for Kansas Only)

Policy CodePolicy CS060KS.02

Change TypeAge applicability clarifiedreferences to InterQual standardizedminor removals

Effective DateJan 1, 2026

Next Review Date

Key ActionObtain prior authorization and reference InterQual CP: Procedures, Ablative or Transarterial Therapy, Liver when requesting coverage for TARE/SIRT.

SourceLink

POLICY UPDATE CHANGES

Added language to indicate this policy applies to individuals 19 years of age and older; transarterial radioembolization/selective internal radiation therapy is covered without further review for individuals younger than 19 years of age.

Replaced instruction to refer to InterQual CP for age ≥18 with a general reference to InterQual CP for medical necessity clinical coverage criteria.

Removed definitions (ECOG, Limited Extra-Hepatic Disease, Refractory, Transarterial Radioembolization) and Supporting Information sections (Description of Services, Clinical Evidence, References).

19+age for policy applicability

Kansasjurisdiction

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Coverage and Medical Necessity Criteria

Initial therapy / Covered indications

Covered when ALL of the following are met

Age: Individual is 19 years of age or older for this policy (individuals younger than 19 are covered without further review).age >= 19

Policy specifies pediatric (<19) covered without further review

Medical necessity: InterQual CP: Procedures, Ablative or Transarterial Therapy, Liver criteria must be met for medical necessity determination; follow InterQual for specific clinical indications (e.g., unresectable HCC, bridge to transplant, unresectable neuroendocrine metastases after systemic therapy failure, unresectable colorectal liver metastases refractory to systemic chemotherapy, unresectable intrahepatic cholangiocarcinoma).refer to InterQual

Policy defers to InterQual for specific clinical criteria

Historic covered indications (reference)

Previously specified covered indications (historic summary)

Historic indications list: Primary unresectable hepatocellular carcinoma (HCC) limited to the liver; HCC as a bridge to liver transplantation; unresectable liver metastases from neuroendocrine tumors when systemic therapy has failed to control symptoms; unresectable colorectal liver metastases with limited extra-hepatic disease refractory to or relapsed following systemic chemotherapy; unresectable intrahepatic cholangiocarcinoma.

Retained as historic reference; current policy references InterQual for medical necessity

Transarterial radioembolization/selective internal radiation therapy (TARE/SIRT) using yttrium-90 microspheres is considered unproven and not medically necessary for all indications other than those specifically listed in this policy or supported by InterQual criteria due to insufficient evidence of efficacy.

Use of TARE/SIRT for indications not listed in this policy or not supported by InterQual CP: Procedures, Ablative or Transarterial Therapy, Liver is unproven and not medically necessary. Providers should reference InterQual for detailed medical necessity criteria for specific clinical situations.

Procedure and Billing Codes

Applicable procedure/HCPCS/CPT codes (reference)mixed

37243	Vascular 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.
75894	Transcatheter therapy, embolization, any method, radiological supervision and interpretation.
79445	Radiopharmaceutical therapy, by intra-arterial particulate administration.
S2095	Transcatheter occlusion or embolization for tumor destruction, percutaneous, any method, using yttrium-90 microspheres

Prior Authorization, Documentation, and Provider Requirements

Prior Authorization

Prior Authorization and Clinical Criteria

Providers should obtain prior authorization as required by the member's benefit plan and UnitedHealthcare policies. Coverage determinations are guided by InterQual® CP: Procedures, Ablative or Transarterial Therapy, Liver; clinical criteria from InterQual must be met for medical necessity determinations.

Refer to InterQual® CP for specific clinical criteria
Obtain prior authorization per plan and payer requirements

Documentation Required

Medical Record Requirements

The patient's medical record must contain documentation that fully supports the medical necessity for the requested services. Documentation should include, but is not limited to, relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures. Documentation must be legible, maintained in the patient's medical record, and made available upon request.

Background and Clinical Context

Transarterial radioembolization/selective internal radiation therapy delivers yttrium-90 microspheres via the hepatic arterial circulation to target primary and metastatic liver tumors. The policy and supporting information note that two commercial 90Y microsphere products exist and have specific regulatory histories; clinicians should be aware of product-specific indications and regulatory status when considering therapy.

FDA approvals and device status have varied by product; the policy references commercially available yttrium-90 microsphere products and their approvals as background information rather than as sole determinants of coverage.

Device and Product Definitions

90Y microsphere products — short descriptors

TheraSphere (glass)Glass yttrium-90 microspheres (BTG/Boston Scientific) approved by FDA under a Humanitarian Device Exemption; PMA granted March 17, 2021 for SIRT local tumor control of solitary HCC tumors 1–8 cm in selected patients.

SIR-Spheres (resin)Resin yttrium-90 microspheres (Sirtex Medical) with FDA premarket approval (P990065, March 5, 2002) indicated for unresectable metastatic colorectal liver tumors with adjuvant intra-hepatic artery chemotherapy (floxuridine).

Regulatory oversightBoth TheraSphere and SIR-Spheres are subject to U.S. Nuclear Regulatory Commission (U.S. NRC) licensing for use.