Cytoreduction and hyperthermic intraperitoneal chemotherapy for the treatment of pseudomyxoma

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1 Medical Policy Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy for the Treatment of Pseudomyxoma Peritonei and Peritoneal Carcinomatosis of Gastrointestinal Origin, and Peritoneal Mesothelioma Table of Contents Policy: Commercial Coding Information Information Pertaining to All Policies Policy: Medicare Description References Authorization Information Policy History Policy Number: 048 BCBSA Reference Number: Related Policies None Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity Medicare HMO Blue SM and Medicare PPO Blue SM Members Cytoreduction and hyperthermic intraperitoneal chemotherapy for the treatment of pseudomyxoma peritonei may be MEDICALLY NECESSARY. Cytoreductive surgery and perioperative intraperitoneal chemotherapy for the treatment of diffuse malignant peritoneal mesothelioma may be MEDICALLY NECESSARY. Cytoreduction and hyperthermic intraperitoneal chemotherapy for the treatment of peritoneal carcinomatosis from colorectal cancer is INVESTIGATIONAL. Prior Authorization Information Commercial Members: Managed Care (HMO and POS) 1

2 Commercial Members: PPO, and Indemnity Medicare Members: HMO Blue SM Medicare Members: PPO Blue SM CPT Codes / HCPCS Codes / ICD-9 Codes The following codes are included below for informational purposes. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member. Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable. CPT Codes CPT codes: Code Description Chemotherapy administration into the peritoneal cavity via indwelling port or catheter Hyperthermia, externally generated; deep (ie, heating to depths greater than 4 cm) Hyperthermia generated by intracavitary probe(s) ICD-9 Diagnosis Codes ICD-9-CM diagnosis codes: Code Description Malignant neoplasm of retroperitoneum Malignant neoplasm of specified parts of peritoneum Secondary malignant neoplasm of retroperitoneum and peritoneum ICD-9 Procedure Codes When the following ICD 9 procedure codes are associated with the service(s) described in this document coverage for the service(s) is aligned with the policy statement. ICD-9-CM procedure codes: Code Description Implantation of chemotherapeutic agent 54.4 Excision or destruction of peritoneal tissue Hyperthermia for treatment of cancer Description Peritoneal dissemination of tumors of gastrointestinal origin occurs from either the appendix or colon. Malignant mesothelioma is a relatively uncommon malignancy that may arise from the mesothelial cells 2

3 lining the pleura, peritoneum, pericardium, and tunica vaginalis testis. Like tumors of GI origin, mesothelioma may spread to the peritoneal cavity as well. Surgical cytoreduction in conjunction with hyperthermic intraperitoneal chemotherapy is designed to removal visible tumor deposits with intraperitoneal chemotherapy to address remaining microscopic disease. By delivering chemotherapy intraperitoneally, drug exposure to the peritoneal surface is increased 20-fold compared to systemic exposure. Summary Several case studies and a systematic review on the use of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy have been published for pseudomysoma peritonei. Although no randomized trials or comparative studies have been published, the data have shown consistent, long-term disease free survival and overall survival with the use of this technique as compared to historic controls. Numerous studies of peritoneal carcinomatosis from colorectal cancer with different levels of evidence support the safety and feasibility of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Existing data suggest a possible improvement in long-term survival of select patients. However, prospective randomized trials are needed to compare best available systemic therapy with and without cytoreductive surgery and hyperthermic intraperitoneal chemotherapy to determine the exact effects of each step, which are currently unknown. An ongoing Phase III trial (NCT ) addresses this question of how much of the survival benefit is derived from the cytoreduction and how much from hyperthermic intraperitoneal chemotherapy, as patients will be randomly assigned to hyperthermic intraperitoneal chemotherapy or no hyperthermic intraperitoneal chemotherapy after complete cytoreductive surgery. The conventional treatment of peritoneal mesothelioma (diffuse malignant type) has resulted in a median survival of approximately 12 months. Although the data on the use of cytoreductive surgery and perioperative intraperitoneal chemotherapy consists of non-randomized case series without control groups, they have shown a significant prolongation of survival ranging from 29.5 to 92 months. Policy History Date Action 11/2011- Medical policy ICD 10 remediation: Formatting, editing and coding updates. 4/2012 7/2011 Reviewed - Medical Policy Group Hematology and Oncology. 9/2010 Reviewed - Medical Policy Group - Hematology and Oncology. 9/2009 Reviewed - Medical Policy Group - Hematology and Oncology. 10/2008 Reviewed - Medical Policy Group Hematology and Oncology. 3/1/2008 Medical Policy 048 effective 3/1/2008 describing covered and non-covered indications Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use 3

4 Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines References 1. Elias D, Honore C, Ciuchendea R et al. Peritoneal pseudomyxoma: results of a systematic policy of complete cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Br J Surg 2008; 95(9): Baratti D, Kusamura S, Deraco M. Diffuse malignant peritoneal mesothelioma: systematic review of clinical management and biological research. J Surg Oncol 2011; 103(8): Glockzin G, Ghali N, Lang SA et al. Results of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis from colorectal cancer. J Surg Oncol 2009; 100(4): Glehen O, Gilly FN, Boutitie F et al. Toward curative treatment of peritoneal carcinomatosis from nonovarian origin by cytoreductive surgery combined with perioperative intraperitoneal chemotherapy. Cancer 2010; 116(24): Elias D, Gilly F, Quenet F et al. Pseudomyxoma peritonei: a French multicentric study of 301 patients treated with cytoreductive surgery and intraperitoneal chemotherapy. Eur J Surg Oncol 2010; 36(5): Vaira M, Cioppa T, de Marco G et al. Management of pseudomyxoma peritonei by cytoreduction + HIPEC (hyperthermic intraperitoneal chemotherapy): results analysis of a twelve-year experience. In Vivo 2009; 23(4): Chua TC, Yan TD, Smigielski ME et al. Long-term survival in patients with pseudomyxoma peritonei treated with cytoreductive surgery and perioperative intraperitoneal chemotherapy: 10 years of experience from a single institution. Ann Surg Oncol 2009; 16(7): Yan TD, Black D, Savady R et al. A systematic review on the efficacy of cytoreductive surgery and perioperative intraperitoneal chemotherapy for pseudomyxoma peritonei. Ann Surg Oncol 2007; 14(2): Maggiori L, Elias D. Curative treatment of colorectal peritoneal carcinomatosis: current status and future trends. Eur J Surg Oncol 2010; 36(7): Rampone B, Schiavone B, Martino A et al. Current role of hyperthermic intraperitoneal chemotherapy in the treatment of peritoneal carcinomatosis from colorectal cancer. World J Gastroenterol 2010: 16(11): Verwaal VJ, van Ruth S, de Bree E et al. Randomized trial of cytoreduction and hyperthermic intraperitoneal chemotherapy versus systemic chemotherapy and palliative surgery in patients with peritoneal carcinomatosis of colorectal cancer. J Clin Oncol 2003; 21(20): Verwaal VJ, Bruin S, Boot H et al. 8-year follow-up of randomized trial: cytoreduction and hyperthermic intraperitoneal chemotherapy versus systemic chemotherapy in patients with peritoneal carcinomatosis of colorectal cancer. Ann Surg Oncol 2008; 5(9): Mahteme H, Hansson J, Berglund A et al. Improved survival in patients with peritoneal metastases from colorectal cancer: a preliminary study. Br J Cancer 2004; 90(2): Elias D, Lefevre JH, Chevalier J et al. Complete cytoreductive surgery plus intraperitoneal chemohyperthermia with oxaliplatin for peritoneal carcinomatosis of colorectal origin. J Clin Oncol 2008; 27(5): Levine EA. The randomized trial of cytoreductive surgery with hyperthermic intraperitoneal chemoperfusion: what it does and does not tell us. Ann Surg Oncol 2008; 15(10):

5 16. Markman M. Intraperitoneal hyperthermic chemotherapy as treatment of peritoneal carcinomatosis of colorectal cancer. Letter to the editor. J Clin Oncol 2004; 22(8): McQuellon RP, Loggie BW, Fleming RA et al. Quality of life after intraperitoneal hyperthermic chemotherapy (IPHC) for peritoneal carcinomatosis. Eur J Clin Oncol 2001; 27(1): vanleeuwen BL, Graf W, Pahlman L et al. Swedish experience with peritonectomy and HIPEC. HIPEC in peritoneal carcinomatosis. Ann Surg Oncol 2008; 15: Glehen O, Kwiatkowski F, Sugarbaker PH et al. Cytoreductive surgery combined with perioperative intraperitoneal chemotherapy for the management of peritoneal carcinomatosis from colorectal cancer: a multi-institutional study. J Clin Oncol 2004; 22(16): Yan TD, Deraco M, Baratti D et al. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for malignant peritoneal mesothelioma: multi-institutional experience. J Clin Oncol 2009; 27(36): National Comprehensive Cancer Network ( NCCN). Colon cancer (V ). Available online at: Last accessed September Esquivel J, Sticca R, Sugarbaker P et al. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the management of peritoneal surface malignancies of colonic origin: a consensus statement. Society of Surgical Oncology. Ann Surg Oncol 2007; 14(1):