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MA07.017g, Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies
Act
by Jun 16, 2025
Effective date
Jun 16, 2025
Identified
Jun 19, 2026
Summary
Independence Blue Cross Medicare Advantage policy MA07.017g has been reissued with expanded coverage for HIPEC (hyperthermic intraperitoneal chemotherapy). Key change: peritoneal carcinomatosis of gastric origin moved from experimental/investigational to medically necessary status, effective June 16, 2025. Eight ICD-10 codes were removed from the policy. Coverage criteria now include specific requirements for gastric origin cases (PCI ≤10, no extraperitoneal metastasis, expected complete cytoreduction).
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What to do
by Jun 16, 2025 · 5 steps
01Billing team must update billing system to classify gastric peritoneal carcinomatosis (using appropriate ICD-10 codes for gastric origin) as medically necessary rather than experimental/investigational for HIPEC procedure claims (CPT 96547, 96548).
02Remove the eight specified ICD-10 codes (C18.1, C56.1, C56.2, C56.3, C56.9, C57.00, C57.01, C57.02) from system edits if currently flagged.
03Prior authorization workflows for gastric cases must now require documentation of: peritoneal cancer index (PCI) ≤10, absence of extraperitoneal metastasis, and anticipated complete cytoreduction.
04Update clinical documentation templates and prior auth review criteria to reflect new gastric origin coverage.
05Providers must include these specific clinical parameters in authorization requests for gastric peritoneal carcinomatosis cases.
If missed: Failure to update prior auth logic will result in appropriate claims being incorrectly denied or requiring manual review.
Codes mentioned
9654796548C45.1C48.0C48.1C48.2C48.8C78.6
Original notice
MA07.017g, Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies
medpolicy.ibx.com · Always check the source before changing claims.
Related changes
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