Medicare AdvantageCoverageMedium impact
Hyperthermia and Ultrasound-Based Ablative Cancer Treatments - Medicare Advantage (Revised)
Humana·Oncology, Radiation Oncology, General Surgery +1 more·Medicare Advantage
Effective date
Apr 1, 2026
We identified it
Aug 25, 2026
Summary
Humana Medicare Advantage updates coverage criteria for hyperthermia and ultrasound-based ablative cancer treatments effective April 1, 2026. The policy establishes specific medical necessity requirements for HIPEC (CPT 96547, 96548), ILI/ILP (CPT 36823), laser therapy (CPT 0970T, 0971T), and HIFU (CPT 55880) procedures. Billing teams must verify patient eligibility against these criteria and ensure proper documentation before claim submission.
Action Required
Before April 1, 2026: Billing team must implement coverage verification logic in claims system for the six affected CPT codes. (1) For CPT 96547/96548 (HIPEC): Verify procedure is combined with cytoreductive surgery AND one of three conditions: gastric cancer without macroscopic peritoneal metastases, peritoneal carcinomatosis without extraperitoneal metastases, or pseudomyxoma peritonei. (2) For CPT 36823 (ILI/ILP): Verify diagnosis is stage III in-transit melanoma. (3) For CPT 0970T/0971T (laser therapy): Verify patient is enrolled in approved IDE study for breast tumors. (4) For CPT 55880 (HIFU): Verify patient meets salvage local therapy candidacy criteria (criteria appears incomplete in source document). Update encounter forms and clinical documentation templates to capture required medical necessity elements. Train billing and clinical staff on new requirements. Configure system edits to flag claims lacking required documentation. Failure to verify criteria will result in claim denials from Humana Medicare Advantage plans.