Transcatheter Arterial Chemoembolization (TACE) of the Liver* Printer-Friendly Version   

Medical Policy: 02.02.08 
Original Effective Date: July 2001 
Reviewed: January 2008 
Revised: May 2006 

This policy applies to all products unless specific contract limitations, exclusions or exceptions apply. Please refer to the member's coverage manual for benefit availability. Managed care guidelines related to referral authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply.

Description: 

Transcatheter arterial chemoembolization (TACE) of the liver is a treatment modality often used as an alternative to conventional systemic or intra-arterial chemotherapy, or in instances where conventional treatment has failed. TACE is intended to induce tumor necrosis through administration of chemotherapy and an embolizing agent directly into the tumor by way of the feeding artery. In addition to tumor necrosis, local dose intensity can be achieved while avoiding some of the systemic toxicities associated with intravenous chemotherapy. TACE may be performed once or multiple times.

Policy: 

Transcatheter arterial chemoembolization (TACE) of the liver may be considered medically necessary for symptomatic treatment of unresectable hepatocellular carcinoma, functional neuroendocrine tumors involving the liver, including carcinoid tumors and pancreatic endocrine tumors, in patients who have failed medical management and meet all of the following criteria:

• Tumor burden of less than 50% of the liver by volume
• Evidence of adequate renal function (i.e., serum creatinine < 2.0 mg/dL)
• Evidence of adequate hepatic function (i.e., serum bilirubin concentration < 2.9 mg/dL)
• No evidence of extra-hepatic metastases

Prior approval is recommended. Submit a prior approval now.

Transarterial chemoembolization (TACE) of the liver is not considered medically necessary for the treatment of liver metastases from other non-neuroendocrine primaries, including colorectal cancer, melanoma, and unknown primaries.

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Procedure Codes and Billing Guidelines: 

• To report provider services, use appropriate CPT** codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
• CPT 37204 Transcatheter occlusion or embolization (e.g., for tumor destruction, to achieve homeostasis, to occlude a vascular malformation), percutaneous, any method, non-central nervous system, non-head or neck
• CPT 75894 Transcatheter therapy, embolization, any method, radiological supervision and interpretation. 

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Selected References: 

• Wallace S, Kan Z, Li C. Hepatic chemoembolization : Clinical and experimental correlation. ACTA Gastroenterologica Belgica 2000 April-Jun;63(2):169-173.
• Al-Bassam SH, Munk PL, Sallomi DF, Morris DC, Lee MJ, Chung SW, Connell, DG. Chemoembolization of hepatic tumors. Australasian Radiology 1999 May; 43 (2):165-174. 
• Ramsey D, Kernagis LT, Soulen MC, Geschwind JF Chemoembolization of hepatocellular carcinoma. Journal of Vascular and Interventional Radiology; September 2002; 13 (9 Suppl): s211-21.
• Sumie S, Yamashita F, Ando E, et al. Interventional radiology for advanced hepatocellular carcinoma: comparison of hepatic artery infusion chemotherapy and transcatheter arterial lipiodol chemoembolization. AJR Am J Roentgenol. 2003 Nov; 181(5): 1327-34.
• Guo WJ, Yu EX, Lui LM, et al. Comparison between chemoembolization combined with radiotherapy and chemoembolization alone for large hepatocellular carcinoma. World J Gastroenterol 2003; 9(8): 1697-1701.
• Sun HC, Tang ZY. Preventive treatments for recurrence after curative resection of hepatocellular carcinoma- A literature review of randomized control trials. World J Gastroenterol 2003; 9(4): 635-640.
• Yang YY, Lin HC, Hou MC, et al. Good response to hepatic arterial chemoembolization in a patient with primary neuroendocrine tumor of the liver. J Chin Med Assoc. 2003 Apr; 66(4): 247-51.
• Guo WE, Yu EX. The long-term efficacy of combined chemoembolization and local irradiation in the treatment of patients with large hepatocellular carcinoma.
• Wu F, Wang ZB, Chen WZ et al. Advanced hepatocellular carcinoma: treatment with high-intensity focused ultrasound ablation combined with transcatheter arterial embolization. Radiology. 2005 May; 235(2):659-6.
• Jang MK, Lee HC, Kim IS et al. Role of additional angiography and chemoembolization in patients who achieved complete necrosis following transarterial chemoembolization. J Gastroenterol Hepatol. 2004 Sep;19(9):1074-80.
• Agarwala SS, Panikkar R, Kirkwood JM, Phase I/II randomized trial of intrahepatic arteial infusion chemotherapy with cisplatin and chemoembolization and polyvinyl sponge in patients with ocular melanoma metastic to the liver. Melanoma Res. 2004 Jun; 14(3):217-22.
• Fiorentini G, Rossi, S, Bonechi F et al. Intra-arterial hepatic chemoembolization in liver metastases from neuroendocring tumors: a phase II study. J Chemother. 2004 Jun; 16(3):293-7.
• Blue Cross and Blue Shield Association. Medical Policy No. 8.01.11; Transcatheter Arterial Chemoembolization to treat Primary or Metastatic Liver Malignancies. 2005.
• Bisselli M, Andreone P, Gramenzi A et al. Transcatheter arterial chemoembolization therapy for patients with hepatocellular carcinoma: a case-controlled study. Clin Gastroenterol Hepatol. 2005; 3(9):918-25.
• Cheng HY, Wang X, Chen D et al. The value and limitation of transcatheter arteial chemoembolization in preventing recurrence of resected hepatocellular carcinoma. World J Gastroenterol. 2005; 11(23):3644-6.
• Molinari M, Kachura JR, Dixon E et al. Transarterial chemoembolization for advanced hepatocellular carcinoma: results from a North American cancer centre. Clin Oncol (R Coll Radiol) 2006; 18(9):684-92.
• Takayasu K, Arii S, Ikai I et al. Prospective cohort study of transarterial chemoembolization for unresectable hepatocellular carcinoma in 8510 patients. Gastroenterology 2006; 131(2):461-9.
• Ruutiaienen AT, Soulen MC, Tuite CM et al. Chemoembolization and bland embolization of neuroendocrine tumor metastases to the liver. J Vasc Interv Radiol 2007; 18(7):847-55. 

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Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave
Des Moines, Iowa 50309

*Prior Approval is recommended for this policy.

**Current Procedural Terminology © 2008 American Medical Association. All Rights Reserved.

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