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Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies

Cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (HIPEC) at the time of surgery may be considered medically necessary for the treatment of:
pseudomyxoma peritonei; and

diffuse malignant peritoneal mesothelioma.

The use of HIPEC may be considered medically necessary in newly diagnosed epithelial ovarian or fallopian tube cancer at the time of interval cytoreductive surgery when ALL of the following criteria are met:

The individual has stage III disease (see Policy Guidelines);

The individual is not eligible for primary cytoreductive surgery or surgery had been performed but was incomplete and will receive neoadjuvant chemotherapy and subsequent interval debulking surgery (see Policy Guidelines); and

It is expected that complete or optimal cytoreduction can be achieved at time of the interval debulking surgery (see Policy Guidelines).

The use of HIPEC in all other settings to treat ovarian cancer, including but not limited to stage IIIC or IV ovarian cancer, is considered investigational.

Cytoreductive surgery plus HIPEC is considered investigational for:

peritoneal carcinomatosis from colorectal cancer, gastric cancer, or endometrial cancer; and

all other indications, including goblet cell tumors of the appendix.

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