ModifiedUnitedHealthcarePolicy CS060KY.09

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

Policy governing the use of yttrium-90 microsphere TARE/SIRT for malignant liver cancers in Kentucky members, with age-specific coverage statements and referenced clinical criteria.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS060KY.09

Change TypeCoverage criteria added for specific indicationsdefinitions and supporting references added.

Effective DateMay 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of arterial mapping/MAA results, hepatic function (including bilirubin), tumor burden, multidisciplinary review, and absence of absolute contraindications.

SourceLink

POLICY UPDATE CHANGES

Added language that TARE/SIRT using yttrium-90 microspheres is proven and medically necessary for specified indications in individuals with ECOG Performance Status 0-2, including HCC unresectable and limited to the liver; HCC as a bridge to transplant; unresectable neuroendocrine tumor liver metastases after failed systemic therapy; unresectable colorectal liver metastases with limited extra‑hepatic disease refractory or relapsed after chemotherapy; and unresectable intrahepatic cholangiocarcinoma.

Added definitions for ECOG Performance Status, Limited Extra‑Hepatic Disease, Refractory, and Transarterial Radioembolization (TARE).

Added Supporting Information sections including Clinical Evidence and References.

KentuckyJurisdiction

ECOG 0-2Required performance status

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Specific covered indications added

18+Members age for InterQual reference

50%–70%Tumor burden relative contraindication

Coverage Criteria and Medical Necessity

Covered Indications (by age group)

Covered when criteria below are met:

Adult coverage reference: For members 18 years and older, TARE/SIRT using yttrium-90 microspheres is proven and medically necessary in certain circumstances; medical necessity clinical coverage criteria are determined by the InterQual CP: Procedures, Ablative or Transarterial Therapy, Liver for age ≥ 18.

See InterQual criteria for age ≥ 18; refer to InterQual links noted in policy.

Pediatric covered indications: For members under 18 years, TARE/SIRT with yttrium-90 is medically necessary when ALL of the following apply: (1) Eastern Cooperative Oncology Group (ECOG) Performance Status is 0, 1, or 2; AND (2) indication is one of: unresectable primary hepatocellular carcinoma limited to the liver; OR primary hepatocellular carcinoma as bridge to liver transplantation; OR unresectable liver metastases from neuroendocrine tumors when systemic therapy has failed to control symptoms; OR unresectable liver metastases from colorectal carcinoma in individuals with Limited Extra‑Hepatic Disease who are refractory to or relapsed following systemic chemotherapy; OR unresectable intrahepatic cholangiocarcinoma.ECOG 0-2 required

Pediatric-specific covered indications added in Summary of Changes (05/01/2025).

Clinical indications and guideline-based coverage stance

Covered when ALL of the following are met (per professional society guidance and guideline statements):

Eligibility for TARE: Patient has unresectable or inoperable primary or secondary liver malignancy with liver‑dominant disease; expected life expectancy of at least 3 months; and multidisciplinary team assessment supports TARE as a treatment option.

Supported by joint society practice parameter and AASLD guidance.

Disease contexts supported by evidence: Includes primary hepatocellular carcinoma (including solitary unresectable HCC and use as bridge to transplant or downstaging), selected colorectal liver metastases, and liver‑dominant neuroendocrine tumor metastases as appropriate contexts for TARE/SIRT.

Guideline and evidence summaries (NCCN, AASLD) support use in these contexts.

Safety and preparatory requirements: Pre‑treatment angiographic mapping and technetium‑99m MAA perfusion scintigraphy must demonstrate acceptable nontarget embolization and hepatopulmonary shunt fraction; adequate hepatic synthetic function or plan for segmental infusion if bilirubin elevated; and ability to catheterize the hepatic artery.

Appropriateness and contraindications

Use and appropriateness considerations (guideline-aligned):

Absolute contraindications must be absent: TARE/SIRT should not be performed if any absolute contraindication is present: inability to catheterize the hepatic artery; fulminant liver failure; mapping angiography/MAA demonstrating uncorrectable nontarget gastrointestinal deposition; unacceptable hepatopulmonary shunt fraction exceeding device‑specific limits; active hepatic infection; or pregnancy except in extraordinary cases with multidisciplinary consultation.

Presence of any absolute contraindication would typically preclude treatment and trigger denial.

Relative contraindications require justification: Relative contraindications include excessive tumor burden in the liver (>50%–70% parenchyma replaced), total bilirubin >2 mg/dL (nonobstructive), prior significant hepatic/upper abdominal radiation, and concurrent systemic therapies that increase toxicity risk — these require clinical justification and documentation of preserved hepatic synthetic function or plans for segmental infusion.Tumor burden >50%–70%; bilirubin >2 mg/dL

High‑risk relative contraindications may lead to denial without supporting documentation.

Coverage considerations and selection criteria

Coverage considerations and clinical context summarized from evidence and guideline statements

Patient selection general criteria

Tumor types with reported use: SIRT/TARE has been reported for uveal melanoma, cutaneous melanoma, breast cancer liver metastases, pancreatic cancer with liver‑dominant disease, colorectal cancer, neuroendocrine tumors, and cholangiocarcinoma; evidence quality varies by tumor type.
Systematic reviews and cohort studies summarized in policy.
Evidence limitations: Most non‑HCC indications have limited, heterogeneous, primarily retrospective evidence; randomized data are lacking for many tumor types, reducing certainty of survival benefit.
Prospective randomized trials are needed for many indications.

Tumor‑specific evidence summaries: Uveal melanoma, breast cancer, and pancreatic cancer series report disease control and variable median OS (examples: UM median OS ~12–19 months; breast cancer median OS ~9.8–11.3 months); outcomes are heterogeneous and prospective randomized comparisons are limited.

Covered Indications (Initial/All)

TARE/SIRT with Y-90 is proven and medically necessary for individuals with ECOG Performance Status 0, 1, or 2 when used for the following indications

Primary HCC unresectable and limited to the liver: Primary hepatocellular carcinoma (HCC) that is unresectable and limited to the liver.ECOG 0-2

Added to coverage rationale in Summary of Changes (05/01/2025).

Primary HCC as bridge to transplant: Primary hepatocellular carcinoma used as a bridge to liver transplantation.ECOG 0-2

Added to coverage rationale in Summary of Changes (05/01/2025).

Neuroendocrine tumor liver metastases after failed systemic therapy: Unresectable liver metastases from neuroendocrine tumors when systemic therapy has failed to control symptoms.ECOG 0-2

For individuals under 18 years of age, TARE/SIRT with yttrium-90 microspheres is limited to a defined set of pediatric indications and is considered medically necessary only when the patient meets the listed criteria, including an ECOG Performance Status of 0, 1, or 2. Covered pediatric indications include unresectable primary hepatocellular carcinoma limited to the liver, HCC as a bridge to liver transplantation, unresectable neuroendocrine tumor liver metastases after systemic therapy has failed to control symptoms, unresectable colorectal liver metastases with Limited Extra‑Hepatic Disease that are refractory to or relapsed after systemic chemotherapy, and unresectable intrahepatic cholangiocarcinoma. All other pediatric uses are considered unproven and not medically necessary.

Absolute contraindications must be absent for TARE/SIRT to proceed. These include inability to catheterize the hepatic artery, fulminant liver failure, mapping angiography/MAA demonstrating uncorrectable nontarget gastrointestinal deposition, unacceptable hepatopulmonary shunt fraction beyond device-specific limits, and active hepatic infection; pregnancy is generally excluded except in extraordinary, multidisciplinary‑consulted circumstances.

Stated alternatively in the policy, absolute exclusions that would preclude treatment and commonly lead to denial are: unsuccessful or impossible hepatic arterial catheterization, fulminant hepatic failure, uncorrectable nontarget deposition on mapping studies, an unacceptable pulmonary shunt fraction on MAA mapping relative to device limits, and active hepatic infection.

Local liver‑directed therapy, including TARE/SIRT, is not recommended as a general approach for patients with poor performance status, extensive extrahepatic disease, or without prior systemic therapy that has demonstrated disease control; such interventions should be reserved for very selected patients after multidisciplinary assessment.

This Medical Policy is informational and provided to assist interpretation of standard UnitedHealthcare benefit plans. Coverage decisions must still conform to the applicable federal, state, or contractual benefit plan terms; in the event of conflict, those contractual or regulatory requirements govern and may override the policy.

Randomized trials (FOXFIRE, SIRFLOX, FOXFIRE‑global) and subsequent guideline reviews demonstrate that adding SIRT to first‑line chemotherapy for metastatic colorectal cancer does not improve overall survival; professional guidance (ASCO 2023) does not recommend routine use of SIRT with first‑line chemotherapy for mCRC.

Extensive hepatic tumor burden is a high‑risk consideration: treatment is generally not appropriate when tumor replaces more than 50%–70% of liver parenchyma unless synthetic hepatic function is preserved and clear justification is documented; similarly, a nonobstructive total bilirubin > 2 mg/dL usually indicates severe hepatic impairment that precludes TARE unless a segmental approach is feasible.

Use of TARE/SIRT for liver metastases from other primary sites (beyond the tumor types with supporting evidence) remains investigational or inconclusive. Systematic reviews report heterogeneous case series and small cohorts with uncertain impact on survival; randomized controlled trials are needed to define clinical utility for these other primaries.

The policy cautions against broad application of TARE/SIRT without careful patient selection; local therapies should be limited to highly selected patients with good performance status, limited liver involvement, and no extrahepatic disease after systemic therapy has shown control.

When policy language describes items as not medically necessary or investigational, those statements must be applied in the context of the member’s specific plan. Explicit NMN or investigational determinations in this document do not replace or supersede applicable contractual, federal, or state plan language—plan terms govern coverage decisions.

Coding and Clinical Thresholds

Procedure CPT Codes (reference)CPT

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

HCPCS CodeHCPCS

S2095

Transcatheter occlusion or embolization for tumor destruction, percutaneous, any method, using yttrium-90 microspheres

Procedure and device codesmixed

No codes listed

inv-19: Tumor burden threshold

Tumor burden thresholdExcessive tumor burden defined as greater than 50%–70% of liver parenchyma replaced by tumor (relative contraindication) — treatment may be considered only if synthetic hepatic function is preserved and with clinical justification.

Clinical implicationIf tumor replaces >50%–70% of liver, TARE/SIRT is high-risk and requires documentation that hepatic synthetic function is adequate to tolerate therapy.

Documentation requirementExtent of liver involvement must be documented in preprocedural imaging and justification provided when treating patients near or above this threshold.

inv-20: Total bilirubin

Total bilirubin thresholdTotal bilirubin > 2 mg/dL (nonobstructive) is a high‑risk relative contraindication to TARE/SIRT.

Prior Authorization, Documentation, and Operational Steps

Prior Authorization

Prior Authorization Required and Medical Necessity Criteria

Transarterial radioembolization (TARE)/selective internal radiation therapy (SIRT) using yttrium-90 microspheres requires prior authorization. Reviewers and ordering providers must confirm medical necessity per age-based InterQual criteria (InterQual® CP: Procedures, Ablative or Transarterial Therapy, Liver for age ≥ 18) or the policy-specific clinical criteria for members under 18. Documentation should clearly map the indication to the applicable criteria and demonstrate that benefits plan, federal/state, and contract requirements have been considered.

Prior authorization is required before scheduling TARE/SIRT.
For members ≥ 18 years, reference InterQual® criteria for medical necessity determination.
For members < 18 years, confirm ECOG 0–2 and one of the policy-listed indications (unresectable HCC limited to liver; bridge to transplant; NET metastases refractory to systemic therapy; colorectal metastases with limited extra‑hepatic disease refractory to systemic chemotherapy; unresectable intrahepatic cholangiocarcinoma).
Benefit contract, federal, or state requirements override this policy where applicable.

Background and Clinical Context

Transarterial radioembolization (TARE), also called selective internal radiation therapy (SIRT), delivers yttrium‑90–loaded microspheres via the hepatic arterial supply to target liver tumors. The microspheres produce localized internal radiation after arterial delivery, allowing high tumor‑directed dose with relative sparing of uninvolved liver parenchyma; TARE/SIRT is used for unresectable primary HCC (including as a bridge to transplant) and for selected unresectable liver metastases when clinical criteria and preparatory mapping studies are met.

Definitions

inv-44: ECOG Performance Status

DefinitionEastern Cooperative Oncology Group (ECOG) Scale of Performance Status — standard measure of functional status from 0 (fully active) to 5 (dead).

Score examples0 = fully active; 1 = restricted in strenuous activity but ambulatory; 2 = ambulatory and capable of self‑care but unable to work; 3 = limited self‑care; 4 = completely disabled.

Coverage requirementECOG Performance Status 0–2 is required for covered pediatric indications and is specified for added coverage rationale.

inv-45: Limited Extra-Hepatic Disease

DefinitionLimited Extra‑Hepatic Disease — metastases limited to the lung with <5 nodules ≤1 cm or a single nodule ≤1.7 cm and/or a single lymph node area <2 cm.

ContextUsed to identify colorectal liver metastases candidates when considering TARE/SIRT in patients refractory to or relapsed after systemic chemotherapy.

Revision History and Policy Changes

2025-05-01Material change - coverage criteria addedLatest

Added Kentucky-specific coverage language: TARE/SIRT using yttrium-90 microspheres is proven and medically necessary for individuals with ECOG Performance Status 0–2 for specified indications (unresectable HCC limited to liver; HCC as bridge to transplant; unresectable neuroendocrine tumor liver metastases after failed systemic therapy; unresectable colorectal liver metastases with Limited Extra‑Hepatic Disease refractory/relapsed after chemotherapy; unresectable intrahepatic cholangiocarcinoma).

2025-05-01Material change - definitions added

Added definitions for ECOG Performance Status, Limited Extra‑Hepatic Disease, Refractory, and Transarterial Radioembolization (TARE).

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS060KY.09

Change TypeCoverage criteria added for specific indicationsdefinitions and supporting references added.

Effective DateMay 1, 2025

Next Review DateN/A

SourceLink

On This Page

Absolute contraindications in practice parameter apply; mapping and shunt assessment required.

Guideline‑supported indications and cautions:

Professional guidelines (NCCN, AASLD, joint society practice parameter) list TARE/SIRT as an arterially directed locoregional therapy option for HCC (including bridge to transplant/downstaging), select intrahepatic cholangiocarcinoma cases, and selected metastatic liver disease when other locoregional options are inappropriate or have failed.

Selection should follow multidisciplinary assessment and guideline recommendations.

See systematic reviews and phase II trials cited in policy.

Device and regulatory considerations: Use of specific Y‑90 products should align with FDA labeling and institutional licensing; TheraSphere and SIR‑Spheres labeling and approvals are described and may inform device selection and procedural planning.

Providers should reference device‑specific labeling when requesting coverage.

Added to coverage rationale in Summary of Changes (05/01/2025).

Colorectal liver metastases with limited extra‑hepatic disease refractory to or relapsed after chemotherapy: Unresectable liver metastases from colorectal carcinoma in individuals with Limited Extra‑Hepatic Disease who are refractory to or relapsed following systemic chemotherapy.ECOG 0-2

Added to coverage rationale in Summary of Changes (05/01/2025).

Intrahepatic cholangiocarcinoma unresectable: Unresectable intrahepatic cholangiocarcinoma.ECOG 0-2

Added to coverage rationale in Summary of Changes (05/01/2025).

Clinical implicationNonobstructive bilirubin >2 mg/dL indicates severe liver impairment and typically precludes radioembolization unless segmental infusion with preserved function is feasible.

Documentation requirementPreprocedural hepatic function tests including bilirubin must be included in authorization documentation to justify treatment when near this threshold.

Documentation Required

Documentation Expectations to Support Authorization

To support prior authorization for TARE/SIRT, submit complete clinical documentation demonstrating indication, prior treatments, multidisciplinary evaluation, and safety assessments. Reviewers expect procedural planning documentation (mapping angiography and technetium-99m MAA perfusion), hepatic function labs, performance status, and imaging that defines tumor burden and extrahepatic disease.

Required: history of prior systemic therapy when indicated (e.g., colorectal metastases refractory to or relapsed following systemic chemotherapy) or documentation why systemic therapy is not appropriate.
Required: multidisciplinary tumor board (MDT) documentation or notes from interventional radiology plus oncology/hepatology/radiation oncology documenting consensus.
Required preprocedural imaging: cross-sectional liver imaging (CT or MRI) with tumor measurements and description of intra- vs extra-hepatic disease.
Required mapping: catheter angiography report, selective angiograms, and technetium-99m MAA hepatic arterial perfusion scintigraphy with calculated lung shunt fraction and demonstration of absence (or corrected absence) of nontarget GI deposition.
Required labs: total bilirubin, albumin, INR, platelets, and other hepatic synthetic function tests to support safety and candidacy.
Documentation of intended targeted approach (segmental/subsegmental vs lobar) and rationale when treating patients with elevated bilirubin or high tumor burden.

Denial Risk

Contraindications and Situations That May Lead to Denial

Contraindications and safety exclusions must be identified up front. Absolute contraindications should lead to denial; relative contraindications require clinical justification and may permit approval in select circumstances.

Absolute contraindications (deny): inability to catheterize the hepatic artery; fulminant liver failure; MAA mapping showing uncorrectable nontarget gastrointestinal deposition; unacceptable lung shunt fraction per device-specific limits; active hepatic infection.
Relative contraindications (may require justification): >50–70% hepatic parenchyma replaced by tumor (unless preserved synthetic function documented); total bilirubin >2 mg/dL without obstructive cause (segmental infusion may be considered for HCC with localized approach); prior significant liver/upper abdominal radiation; concurrent systemic therapies that increase liver toxicity — provide oncologic rationale and timing.
Pregnancy: generally contraindicated; consideration only in extraordinary multidisciplinary-consensus cases with documented risk–benefit discussion.

Billing Rule

Coding, Billing, and Operational Reminders

Operational reviewers must verify code and claims submission expectations. Codes provided in policy are informational and do not guarantee coverage. Confirm benefit plan applicability before approval and include the relevant procedure and HCPCS codes on the prior authorization request.

Coding is for reference only and does not imply coverage or reimbursement.
Commonly referenced procedure codes: CPT 37243, 75894, 79445; HCPCS S2095 — include the clinical rationale when submitting these codes.
Prior authorization verification must include life expectancy (≥ 3 months typical expectation per society statements), ECOG performance status, and documentation of MDT involvement when applicable.

Note

Prior Authorization and Criteria Reference (Operational)

Follow plan-specific prior authorization processes and ensure reviewers check InterQual use, federal/state/contract requirements, and device labeling when applicable. FDA approvals for TheraSphere® and SIR-Spheres® are informational; they do not by themselves establish coverage.

Reviewers must confirm which set of criteria applies (InterQual for adults, policy criteria for pediatric patients) and document which standard was used.
Device labeling and FDA PMA/HDE indications should be considered but do not override coverage determinations based on medical necessity and benefit terms.
Ensure prior authorization requests include device-specific safety assessments (e.g., lung shunt fraction thresholds for the intended microsphere).

Selection implicationPresence of Limited Extra‑Hepatic Disease supports consideration for TARE/SIRT in select patients rather than widespread extrahepatic disease which contraindicates local therapy.

inv-46: Refractory

DefinitionRefractory — cancer that does not respond to treatment; may be resistant at the start or become resistant during therapy.

Usage in policyTerm used to indicate failure of prior systemic therapy (eg, neuroendocrine or colorectal liver metastases refractory to systemic chemotherapy) as part of coverage criteria.

Clinical implicationDocumentation should demonstrate prior systemic therapy and evidence of treatment failure or relapse when refractory status is claimed.

inv-47: Transarterial Radioembolization (TARE)

DefinitionTransarterial Radioembolization (TARE) — intra‑arterial therapy using yttrium‑90–impregnated microspheres; also called radioembolization or selective internal radiation therapy (SIRT).

MechanismDelivers Y‑90–loaded microspheres via the hepatic arterial supply to irradiate liver tumors while sparing non‑target tissue when mapped appropriately.

SynonymsAlso referred to as RE (radioembolization) or SIRT in clinical guidelines and the policy.

inv-48: Mapping angiography and MAA perfusion scintigraphy

DefinitionMapping angiography and technetium‑99m macroaggregated albumin (MAA) perfusion scintigraphy — pre‑treatment angiographic evaluation and MAA hepatic arterial perfusion scintigraphy to assess for nontarget deposition and hepatopulmonary shunt fraction.

PurposeUsed to identify uncorrectable nontarget gastrointestinal deposition and to measure pulmonary shunt fraction relative to device‑specific limits prior to TARE.

Documentation requirementResults of mapping angiography and MAA scintigraphy must be provided to demonstrate acceptable nontarget deposition and shunt fraction for authorization.

inv-49: Liver-dominant tumor burden

DefinitionLiver‑dominant tumor burden — tumor involvement is primarily in the liver (not necessarily exclusive) and is a selection criterion for consideration of SIRT/TARE.

Clinical implicationGuidelines note TARE/SIRT is appropriate when disease is liver‑dominant and multidisciplinary assessment supports local therapy in the context of life expectancy and performance status.

Selection noteLiver‑dominant disease does not require absolute absence of extrahepatic disease but favors patients with limited extrahepatic involvement.

inv-50: Locoregional therapies (LRT)

DefinitionLocoregional therapies (LRT) — therapies delivered directly to the liver or tumor, including bland TAE, TACE, DEB‑TACE, SIRT/TARE, ablation, and EBRT/SBRT, used for control, downstaging, or bridging to transplant.

RoleTARE/SIRT is one option among locoregional therapies and may be used when other modalities are inappropriate, have failed, or as a bridge to transplant per guideline recommendations.

Selection considerationsChoice of LRT should follow multidisciplinary assessment considering tumor type, extent of disease, liver function, and prior therapies.

inv-51: SIR-Spheres (resin 90Y microspheres)

DeviceSIR‑Spheres — resin‑based yttrium‑90 microspheres (Sirtex Medical) approved by FDA for treatment of unresectable metastatic liver tumors from primary colorectal cancer with adjuvant intra‑hepatic artery chemotherapy (FUDR).

Regulatory noteSIR‑Spheres received FDA premarket approval (P990065) and their use is subject to U.S. NRC licensing requirements.

Clinical contextDevice labeling and regulatory status should be considered when requesting coverage and during procedural planning.

inv-52: TheraSphere (glass 90Y microspheres)

DeviceTheraSphere — glass‑based yttrium‑90 microspheres indicated under FDA Humanitarian Device Exemption (and subsequently PMA for specified uses) for unresectable hepatocellular carcinoma and certain local tumor control indications.

Regulatory noteTheraSphere was initially approved under a Humanitarian Device Exemption and has more recent PMA labeling specifying solitary tumor control in selected patients (see FDA PMA details).

Clinical contextDevice labeling specifies patient selection (eg, Child‑Pugh A, well‑compensated liver function, no macrovascular invasion) relevant to candidacy and authorization review.

inv-53: ECOG Performance Status (duplicate/new definition chunk)

Definition (added language)ECOG Performance Status — Eastern Cooperative Oncology Group scale (0–5) defining functional status; newly added in policy definitions to align coverage criteria.

Coverage linkPolicy explicitly requires ECOG 0–2 for the pediatric covered indications added in the 05/01/2025 revision.

Reference textFull ECOG categories (0–5) are described in the policy definitions section for clinical assessment.

inv-54: Limited Extra-Hepatic Disease (added definition chunk)

Definition (added language)Limited Extra‑Hepatic Disease — defined in policy and added to Definitions in the 05/01/2025 revision to specify metastatic burden parameters for coverage decisions.

Practical criteriaPolicy definition references lung metastases criteria (<5 nodules ≤1 cm or single ≤1.7 cm) and limited nodal disease (<2 cm).

Use in coverageApplied to colorectal liver metastases coverage when refractory to or relapsed after systemic chemotherapy.

inv-55: Refractory (added definition chunk)

Definition (added language)Refractory — defined in the policy as cancer unresponsive to prior therapy; added explicitly in the 05/01/2025 revision to support coverage criteria requiring prior systemic therapy failure for some indications.

Coverage implicationRefractory status must be documented (eg, progression on or after systemic therapy) to meet coverage for specified metastatic indications.

DocumentationClinical records should show prior systemic regimens tried and evidence of nonresponse or relapse when refractory is claimed.

inv-56: TARE / SIRT (added definition chunk)

Definition (added language)TARE / SIRT — Transarterial Radioembolization / Selective Internal Radiation Therapy using yttrium‑90 microspheres; added to policy definitions to clarify terminology for coverage criteria.

Procedure prerequisitesPolicy emphasizes need for mapping angiography and MAA perfusion scintigraphy to assess nontarget deposition and pulmonary shunt before TARE/SIRT.

Coverage linkageTARE/SIRT indications in the policy require multidisciplinary assessment, adequate hepatic function, and absence of absolute contraindications per policy guidance.