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    v1.0.28
    OpenPayerPolicy UpdatesClinical/Medical PolicyWPS Health Tumor Treating Fields Coverage | OpenPa…
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    CurrentWPS Health InsurancePolicy PUM 250-0024-1812

    Durable Medical Equipment (DME): Tumor Treating Fields (Alternating Electric Field Therapy) Medical Guideline

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    This guideline governs coverage and prior authorization for the tumor treating fields device, also called alternating electric field therapy, for members with newly diagnosed glioblastoma multiforme. It addresses the device only and does not govern chemotherapy drugs; coverage remains subject to the member’s benefit plan, applicable law, and required clinical review.

    Policy Summary
    PayerWPS Health Insurance
    PolicyTumor Treating Fields (Alternating Electric Field Therapy)
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateOct 1, 2026
    Next Review DateN/A
    Key ActionObtain prior authorization and submit a Standard Written Order with clinical documentation before requesting coverage.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    Newly diagnosed GBM onlyCovered disease indication
    6Initial criteria
    18 hours/dayTherapy use
    7 weeksInitiation window

    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.

    3 monthsReview interval
    Not medically necessaryRecurrent GBM

    Coverage Criteria

    Initial therapy for newly diagnosed GBM

    Covered when ALL of the following are met:

    Initial therapy criteria

    • Disease diagnosis: The member has histologically confirmed WHO grade IV astrocytoma, newly diagnosed, supratentorial glioblastoma multiforme.WHO grade IV; supratentorial; newly diagnosed
    • Prior treatment: The member has received initial treatment with maximal debulking surgery when feasible, followed by chemotherapy and radiotherapy.
    • Timing of initiation: Tumor treating fields therapy is initiated within 7 weeks from the last dose of concomitant chemotherapy or radiotherapy, whichever is later.Within 7 weeks
    • Disease status: The member has no evidence of progression by Response Assessment in Neuro-Oncology criteria.No progression by RANO criteria
    • Functional status: The member has a Karnofsky Performance Score of at least 70.KPS >= 70
    • Expected adherence: The member will use tumor treating fields therapy for an average of 18 hours per day.18 hours/day average

    Continuation therapy

    Continued coverage beyond the first three months requires ALL of the following:

    Continuation therapy criteria

    • In-person clinical re-evaluation: The treating practitioner conducts an in-person clinical re-evaluation no sooner than the 60th day and no later than the 91st day after therapy initiation.Evaluation during days 60-91
    • Clinical benefit: The treating practitioner documents that the member continues to use and benefit from tumor treating fields therapy.
    • Objective adherence evidence: The treating practitioner reviews objective evidence of adherence, defined as average use for 18 hours per day, except on days when the treating practitioner has documented a medical need to limit or interrupt treatment.18 hours/day average

    Recurrent glioblastoma multiforme (GBM) and use of tumor treating fields for any indication other than newly diagnosed GBM are considered not medically necessary.

    Chemotherapy drugs are outside the scope of this tumor treating fields device guideline. Drug coverage and authorization are addressed through the Drug Prior Authorization List.

    Tumor treating fields therapy for recurrent glioblastoma multiforme is considered not medically necessary.

    For newly diagnosed GBM, use of tumor treating fields when the listed medical-necessity criteria are not met is considered not medically necessary.

    Use of tumor treating fields for any indication other than newly diagnosed GBM is considered not medically necessary.

    Clinical and Coding Parameters

    Therapy initiation interval
    Initiation deadlineWithin 7 weeks
    Timing referenceThe last dose of concomitant chemotherapy or radiotherapy
    Dose usedWhichever dose is later
    Karnofsky Performance Score
    Minimum KPSAt least 70
    AssessmentKarnofsky Performance Score
    Coverage requirementThe member must have a KPS of at least 70

    Provider Actions and Authorization

    Prior Authorization

    Obtain prior authorization before therapy

    Prior authorization is required under applicable benefit requirements. When all coverage criteria are met, initial approval may be issued for three months; continued use requires Health Plan Medical Director review every three months.

    Prior Authorization

    Complete the three-month continuation review

    For coverage beyond the initial three months, the treating practitioner must conduct an in-person clinical re-evaluation no sooner than the 60th day and no later than the 91st day after therapy initiation. Document continued use and clinical benefit, and review objective evidence of adherence, defined as average use of 18 hours per day except when a documented medical need requires limitation or interruption.

    Documentation Required

    Background

    Tumor treating fields (TTFs), also known as alternating electric field therapy, are low-intensity alternating electric fields used to treat glioblastoma multiforme. The therapy is intended to disrupt tumor-cell division and inhibit tumor growth.

    Definitions

    Tumor Treating Fields (TTFs)
    DefinitionLow-intensity alternating electric fields used as treatment for glioblastoma multiforme
    Therapeutic actionDisrupt the division of tumor cells
    Treatment purposeInhibit tumor growth
    Alternating Electric Field Therapy
    TermAlternating Electric Field Therapy
    MeaningAnother name for tumor treating fields therapy
    UseTreatment for glioblastoma multiforme

    Medical Necessity Criteria

    Tumor treating fields device criteria

    The tumor treating fields device is medically necessary for newly diagnosed GBM only when ALL of the following criteria are met:

    DME medical necessity criteria

    • Disease diagnosis: The member has histologically confirmed newly diagnosed supratentorial WHO grade IV glioblastoma multiforme.WHO grade IV; supratentorial; newly diagnosed
    • Prior treatment: The member has received maximal debulking surgery when feasible, followed by chemotherapy and radiotherapy.
    • Timing of initiation: Therapy is initiated within 7 weeks of the later final dose of concomitant chemotherapy or radiotherapy.Within 7 weeks

    Required Documentation

    Documentation Required

    Submit the diagnosis-specific written order

    Include a Standard Written Order prescribed by a qualified healthcare provider with the authorization request. The order must concern the member’s diagnosis.

    Documentation Required

    Include complete medical records

    Include medical record documentation supporting the diagnosis and medical necessity, including relevant surgical, chemotherapy, radiation, and other treatment history. Document continued need or use when applicable.

    Documentation Required

    Document continued use at each extension

    For continued use, submit updated clinical documentation relevant to disease status with each authorization-extension request. Continued use is reviewed by the Health Plan’s Medical Director every three months.

    Not Covered Indications

    The guideline does not cover tumor treating fields for recurrent glioblastoma multiforme or for any indication other than newly diagnosed GBM. Such use is considered not medically necessary; use for a condition or diagnosis outside the listed indications may also be considered experimental, investigational, and unproven to affect health outcomes.

    Policy Summary
    PayerWPS Health Insurance
    PolicyTumor Treating Fields (Alternating Electric Field Therapy)
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateOct 1, 2026
    Next Review DateN/A
    Key ActionObtain prior authorization and submit a Standard Written Order with clinical documentation before requesting coverage.
    SourceLink
    On This Page
    Coverage CriteriaClinical and Coding ParametersProvider Actions and AuthorizationBackgroundDefinitionsMedical Necessity CriteriaRequired DocumentationNot Covered Indications
    Average daily therapy use
    Required average use18 hours per day
    TherapyTumor treating fields therapy
    Measurement basisAverage daily use
    Continuation clinical re-evaluation window
    Review windowNo sooner than the 60th day and no later than the 91st day after therapy initiation
    Review typeIn-person clinical re-evaluation by the treating practitioner
    Continuation timingRequired for coverage beyond the first three months of therapy

    Include the Standard Written Order

    Submit a Standard Written Order prescribed by a qualified healthcare provider concerning the member’s diagnosis with the authorization request.

    Documentation Required

    Provide clinical records and treatment history

    Submit medical record information documenting the diagnosis, medical necessity, and relevant surgical, chemotherapy, radiation, and other treatment history. Include continued need or use when applicable.

    Billing Rule

    Submit compliant coding

    Submit current coding for the item or service that meets all applicable coding guidelines.

    Documentation Required

    Update documentation for each extension

    For continued therapy, submit updated clinical documentation relevant to disease status with each authorization-extension request. The documentation must support the required clinical re-evaluation and benefit from therapy.

    Denial Risk

    Recurrent GBM is not medically necessary

    Tumor treating fields therapy for recurrent glioblastoma multiforme is considered not medically necessary and is at risk for denial.

    Denial Risk

    Verify the indication before requesting coverage

    Use of tumor treating fields for any indication other than newly diagnosed GBM is considered not medically necessary. Use for a condition or diagnosis other than one listed in the indications may also be considered experimental, investigational, and unproven to affect health outcomes.

    Denial Risk

    Meet all medical-necessity criteria

    Use for newly diagnosed GBM when the stated medical-necessity criteria are not met is considered not medically necessary and may be denied.

    Denial Risk

    Confirm plan and authorization requirements

    Review the member’s contract and endorsements for exclusions, prior authorization, and benefit requirements before submitting the request. Failure to satisfy applicable contract, benefit, prior authorization, or documentation requirements may affect coverage; continued use requires Medical Director review every three months and updated clinical documentation.

    Novo TTF Therapy
    TermNovo TTF Therapy
    MeaningA name used for tumor treating fields therapy
    Treatment associationTumor treating fields therapy is used as treatment for glioblastoma multiforme
    Optune
    TermOptune®
    MeaningA name used for tumor treating fields therapy
    Treatment associationTumor treating fields therapy is used as treatment for glioblastoma multiforme
    Adherence to therapy
    Average use18 hours per day
    EvidenceObjective evidence of adherence reviewed by the treating practitioner
    Medical exceptionDays when the treating practitioner has documented a medical need to limit or interrupt treatment are excluded
  1. Disease status: The member has no evidence of progression by Response Assessment in Neuro-Oncology criteria.No progression by RANO criteria
  2. Functional status: The member has a Karnofsky Performance Score of at least 70.KPS >= 70
  3. Expected adherence: The member will use tumor treating fields therapy for an average of 18 hours per day.18 hours/day average
    4. Billing Rule

    Use current compliant coding

    Ensure that submitted item or service coding is current and meets all applicable coding guidelines.