HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
I-91-016
Topic:
Intraperitoneal Chemotherapy
Section:
Injections
Effective Date:
November 30, 2015
Issued Date:
March 18, 2019
Last Revision Date:
August 2016
Annual Review:
August 2016
 
 

Early intraperitoneal chemotherapy (EIPC) is administered directly into the abdominal cavity. The first dose of chemolytic agents may be infused post-surgery with subsequent doses given over a course of several days.

Hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC), also referred to as intraperitoneal hyperthermic chemotherapy (IPHC), is instilled during surgery, via an open or closed abdominal approach. The heated chemolytic agent is infused into the peritoneal cavity, raising the temperature of the tissues within the cavity to 106–108 °Fahrenheit (F). Because various tissue thicknesses are present within the peritoneal cavity, there is a concern that the entire cavity may not be receiving an even exposure to the medication. Extensive surgical debulking is imperative.

Policy Position

Early Intraperitoneal chemotherapy (EPIC) or Hyperthermic intraoperative Intraperitoneal chemotherapy (HIPEC) may be considered medically necessary when used in combination with cytoreductive surgery for ANY ONE of the following indications:

  • Stage III  optimally debulked (residual tumor less than or equal to 1.0 cm in diameter) epithelial ovarian cancer; or
  • Optimally debulked pseudomyxoma peritonei or mesothelioma of the peritoneum; or
  • Optimally debulked peritoneal surface malignancies from tumors of gastrointestinal origin (excluding pancreas).

EPIC or HIPEC reported for any other indication is considered experimental/investigational, and therefore, non-covered.  Scientific evidence does not support the use of EPIC and HIPEC for any other indications.

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Place of Service: Inpatient/Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

The administration of intraperitoneal chemotherapy is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.


The policy position applies to all commercial lines of business



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

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