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Detection and Quantification of Circulating Tumor Cells in the Management of Patients with Cancer

» Summary» Procedure Codes
» Description» Selected References
» Prior Approval» Policy History
» Policy

Medical Policy: 02.04.16 
Original Effective Date: March 2008 
Reviewed: November 2014 
Revised: November 2014 

Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary based on contract, and individual member benefits must be verified. Wellmark determines medical necessity only if the benefit exists and no contract exclusions are applicable. This medical policy may not apply to FEP. Benefits are determined by the Federal Employee Program.

This Medical Policy document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy will be reviewed regularly and be updated as scientific and medical literature becomes available.


Studies have suggested that the presence of circulating tumor cells (CTCs) in patients with metastatic carcinoma is associated with short survival. Quantifying circulating tumor cells might be a useful technique to provide an immediate assessment of response to chemotherapy rather than relying on changes in imaging studies. Also, the presence of circulating tumor cells has been investigated as an additional prognostic factor in women with breast cancer without metastases which could be used to determine the need for additional adjuvant chemotherapy.


Research over more than 10 years has focused the development of methodologies with improved sensitivity and specificity. Physical techniques such as size filtration, density gradient centrifugation, and microscopic morphology continue to be used. However, biological techniques such as immunomagnetic isolation, flow cytometry, immunofluorescent microscopy, reverse transcriptase-polymerase chain reaction (RT-PCR), polymerase chain reaction (PCR), and fluorescence in situ hybridization (FISH) have been added to provide required specificity.


The CellSearch™ system (Veridex) is an example of immunofluorescent technology. The technique involves identification of the circulating tumor cells in blood which are tagged using antibody-coated magnetic beads that recognize cell surface antigens. The cells are then labeled with fluorescent dyes, which can then be quantified by a semiautomated fluorescent-based microscopy system.


Regulatory Status

The CellSearch™ system (Veridex) has received U.S. Food and Drug Administration (FDA) marketing clearance through the 510(k) process for monitoring metastatic breast cancer (January 2004), for monitoring metastatic colorectal cancer (November 2007), and for monitoring metastatic prostate cancer (February 2008). Veridex LLC, a Johnson & Johnson company, markets the CellSearch™ system. It uses automated instruments manufactured by Immunicon Corp. for sample preparation (Cell Tracks® AutoPrep) and analysis (CellSpotterAnalyzer®), together with supplies, reagents, and epithelial cell control kits manufactured by Veridex.


American Society of Clinical Oncology: Recommendations for the use of tumor markers in breast cancer, published in 2007, indicate that the measurement of CTCs should not be used to make the diagnosis of breast cancer or to influence any treatment decisions in those with breast cancer. They should not be used in the prevention, screening, treatment, or surveillance of breast cancer.


National Comprehensive Care Network (NCCN): Their 2014 Clinical Practice Guidelines do not include recommendations regarding detection of CTCs used in the management of patients with colon or prostate cancer.


National Academy of Clinical Biochemistry (NACB): In 2009, NABC issued a guideline on the use of tumor markers in testicular, prostate, colorectal, breast, and ovarian cancer. The only mention of CTCs was related to prostate cancer. The panel concluded that the measurement of circulating prostate cancer cells was not sufficiently validated to recommend its application in routine clinical practice.


Prior Approval: 


Not applicable



Detection and quantification of circulating tumor cells is considered investigational in the management of patients with cancer.


While levels of circulating tumor cells may be associated with the presence of metastatic disease and prognosis, the prospective use of this information to impact care has not been demonstrated. The clinical utility of quantifying CTCs remains unproven at this time. Published data is inadequate to determine how such measurements should guide treatment decisions and whether those treatment decisions could result in beneficial outcomes.  Given the insufficient evidence to evaluate the impact on net health outcomes, the assessment of circulating tumor cells is investigational for the management of cancer.


Procedure Codes and Billing Guidelines: 

  • To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.
  • 86152 Cell enumeration using immunologic selection and identification in fluid specimen (eg, circulating tumor cells in blood).
  • 86153 Cell enumeration using immunologic selection and identification in fluid specimen (eg, circulating tumor cells in blood); physician interpretation and report, when required.


Selected References: 

  • Cristofanilli M, Budd GT, Ellis MJ et al. Circulating tumor cells, disease progression and survival in metastatic breast cancer. NEJM 2004; 351:781-91.
  • Harris L, Fritsche H, Mennel R et al. American Society of Clinical Oncology 2007 Update of Recommendations for the Use of Tumor Markers in Breast Cancer. J Clin Oncol. 2007 Nov 20;25(33):5287-312.
  • Budd GT, Cristofanilli M, Ellis MJ et al. Circulating tumor cells versus imaging-predicting overall survival in metastatic breast cancer. Clin Cancer Res. 2006  Nov 1;12(21):6321-2.
  • Hayes DF, Cristofanilli M, Budd GT et al. Circulating tumor cells at each follow-up time point during therapy of metastatic breast cancer patients predicts progression-free and overall survival. Clin Cancer Res. 2006 Jul 15;12(14 Pt 1):4218-24.
  • Liu MC, Shields PG, Warren RD et al. Circulating Tumor Cells: A Useful Predictor of Treatment Efficacy in Metastatic Breast Cancer. J Clin Oncol. 2009 Sep 14. [Epub ahead of print]
  • Cohen SJ, Punt CJA, Iannotti N et al. Relationship of Circuating Tumor Cells to Tumor Response, Progression-Free Survival, and Overall Survival in Patients with Metastatic Colorectal Cancer. J Clin Oncol. 2008 Jul 1; 26(19): 3213-3221.
  • Serrano Fernadez MJ, Alvarez Merino JC, Martinez Zubiaurre I et al. Clinical relevance associated to the analysis of circulating tumour cells in patients with solid tumours. Clin Transl Oncol. 2009 Oct; 11(10):659-68.
  • Gazzaniga P, Naso G, Gradilone A et al. Chemosensitivity profile assay of circulating cancer cells (CTCs): prognostic and predictive value in epithelial tumors. In J Cancer. 2009 Oct 9. [Epub ahead of print]
  • Nakamura S, Yagata H, Ohno S et al. Multi-center study evaluating circulating tumor cells as a surrogate for response to treatment and overall survival in metastatic breast cancer. Breast Cancer. 2009 Aug 1. [Epub ahead of print]
  • Mostert B, Sleijfer S, Foekens JA et al. Circulating tumor cells (CTCs): detection methods and their clinical relevance in breast cancer. Cancer treat Rev. 2009 Aug; 35(5): 463-74.
  • Helo P, Cronin AM, Danila DC et al. Circulating prostate tumor cells detected by reverse transcription-PCR in men with localized or castration-refractory prostate cancer: concordance with CellSearch assay and association with bone metastases and with survival. Clin Chem. 2009 Apr;55(4):765-73.
  • Iinuma H, Watanabe T, Mimori K et al. Clinical significance of circulating tumor cells, including cancer stem-like cells, in peripheral blood for recurrence and prognosis in patients with Dukes' Stage B and C colorectal cancer. J Clin Oncol 2011 Apr 20; 29(12): 1547-55. Epub 2011 Mar 21.
  • Krebs MG, Sloane R, Priest L et al. Evaluation and prognostic significance of circulating tumor cells in patients with non-small-cell lung cancer. J Clin Oncol 2011 Apr 20; 29(12): 1556-63. Epub 2011 Mar 21.
  • Tanaka F, Yoneda K, Kondo N et al. Circulating tumor cells as a diagnostic marker in primary lung cancer. Clin Cancer Res 2009; 15(22):6980-6.
  • Pierga JY, Hajage D, Bachelot T, Delaloge S, et al. High independent prognostic and predictive value of circulating tumor cells compared with serum tumor markers in a large prospective trial in first-line chemotherapy for metastatic breast cancer patients. Ann Oncol. 2012 Mar;23(3):618-24.
  • Zhang L, Riethdorf S, Wu G, Wang T, et al. Meta-analysis of the prognostic value of circulating tumor cells in breast cancer. Clin Cancer Res. 2012 Oct 15;18(20):5701-10.
  • American Society of Clinical Oncology (ASCO), American Society of Clinical Oncology 2007 Update of Recommendations for the Use of Tumor Markers in Breast Cancer. Published in Journal of Clinical Oncology, Vol 25, Issue 33 (November), 2007: 5287-5312.
  • American Cancer Society. What's New in Breast Cancer Research and Treatment?  New Laboratory Tests, Circulating Tumor Cells.
  • Canadian Agency for Drugs and Technologies in Health. The CellSearch System for Detecting Circulating Tumor Cells in Advanced Ovarian Cancer: Clinical Benefit and Cost Effectiveness. November 16, 2012.
  • Agency for Healthcare Research and Quality (AHRQ). Use of Tumor Markers in Testicular, Prostate, Colorectal, Breast and Ovarian Cancers. 2009.
  • British Journal of Cancer. A Direction Comparison of CellSearch and ISET for Circulating Tumor Cell Detection in Patients with Metastatic Carcinomas. September 6, 2011; 105(6): 847-853
  • UpToDate. Systemic Treatment for Metastatic Breast Cancer: General Principles. Daniel F. Hayes, M.D.. Topic last updated November 4, 2013.
  • UpToDate. Prostate Cancer: Risk Stratification and Choice of Treatment. Eric A. Klein, M.D.. Topic last updated November 14, 2013.
  • National Comprehensive Cancer Network (NCCN): Version 3.2013 Breast Cancer; Version 2.2014 Colon cancer; Version 4.2013 Prostate Cancer.
  • National Academy of Clinical Biochemistry (NACB). The use of tumor markers in testicular, prostate, colorectal, breast and ovarian cancer. 2009. Available online at:


Policy History: 


Date                                        Reason                               Action

January 2011                          Annual review                     Policy renewed

January 2012                          Annual review                     Policy renewed

January 2013                          Annual review                     Policy renewed

January 2014                          Annual review                     Policy renewed

November 2014                       Annual review                     Policy revised


Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc.   They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.

*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.

Contact Information
New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:
  Wellmark Blue Cross and Blue Shield
  Medical Policy Analyst
  P.O. Box 9232
  Des Moines, IA 50306-9232
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