C IGNA H EALTH C ARE C OVERAGE P OSITION Subject Selective Internal Radiation Therapy (SIRT) Revised Date ............................. 5/15/2008
Original Effective Date ............. 6/15/2004
Next Review Date.5/15/2009
Coverage Position Number ............. 0081 Table of Contents
Coverage Position............................................... 1
General Background ........................................... 2
Coding/Billing Information ................................... 9
References.......................................................... 9 Hyperlink to Related Coverage Positions
Cryoablation of Liver Tumors
Intensity-Modulated Radiation Therapy
(IMRT)
Intraperitoneal Hyperthermic Chemotherapy
(IPHC)
Liver Transplant: Cadaveric and Living Donor Percutaneous Ethanol Injection (PEI) for Liver Cancer Radiofrequency Ablation (RFA) for Primary and Metastatic Cancers of the Liver Serum Markers for Liver Disease
Transcatheter Arterial Chemoembolization (TACE) Transjugular Intrahepatic Portosystemic
Shunts (TIPS) INSTRUCTIONS FOR USE
Coverage Positions are intended to supplement certain standard CIGNA HealthCare benefit plans. Please note, the terms of a
participants particular benefit plan document [Group Service Agreement (GSA), Evidence of Coverage, Certificate of Coverage,
Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which
these Coverage Positions are based. For example, a participants benefit plan document may contain a specific exclusion related to
a topic addressed in a Coverage Position. In the event of a conflict, a participants benefit plan document always supercedes the
information in the Coverage Positions. In the absence of a controlling federal or state coverage mandate, benefits are ultimately
determined by the terms of the applicable benefit plan document. Coverage determinations in each specific instance require
consideration of 1) the terms of the applicable group benefit plan document in effect on the date of service; 2) any applicable
laws/regulations; 3) any relevant collateral source materials including Coverage Positions and; 4) the specific facts of the particular
situation. Coverage Positions relate exclusively to the administration of health benefit plans. Coverage Positions are not
recommendations for treatment and should never be used as treatment guidelines. Proprietary information of CIGNA. Copyright