HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 
Medical Policy:
S-137-005
Topic:
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors
Section:
Surgery
Effective Date:
September 17, 2018
Issued Date:
September 17, 2018
Last Revision Date:
August 2018
Annual Review:
August 2018
 
 

In radiofrequency ablation (RFA), heat is projected into a tumor by a high-frequency, alternating current that flows from electrodes. The cells killed by RFA are gradually replaced by fibrosis and scar tissue. RFA can be performed percutaneously, laparoscopically, or as an open procedure.

Policy Position Coverage is subject to the specific terms of the member's benefit plan.

Osteolytic Bone Pain

RFA may be considered medically necessary to palliate pain in individuals with osteolytic bone metastases who have failed or are poor candidates for standard treatments such as radiation or opioids.

20982

76940

 

 

 

 

 


Osteoid Osteomas

RFA may be considered medically necessary to treat osteoid osteomas that cannot be managed successfully with medical treatment.

20982

76940

 

 

 

 

 


Localized Renal Cell Carcinoma

RFA may be considered medically necessary to treat localized renal cell carcinoma that is no more than 4 cm in size when ANY ONE of the following criteria is met: 

  • In order to preserve kidney function in individuals with significantly impaired renal function (i.e., the inidividual has one (1) kidney or renal insufficiency defined by a glomerular filtration rate [GFR] of less than 60 mL/min/m2) when the standard surgical approach (i.e., resection of renal tissue) is likely to substantially worsen existing kidney function; or
  • The individual is not considered a surgical candidate.

50542

50592

76940

 

 

 

 


Isolated Peripheral Non-Small Cell Lung Cancer

RFA may be considered medically necessary to treat an isolated peripheral non-small-cell lung cancer lesion that is no more than three (3) cm in size when ALL the following criteria are met: 

  • Surgical resection or radiation treatment with curative intent is considered appropriate based on stage of disease, however, medical comorbidity renders the individual unfit for those interventions; and
  • Tumor is located at least 1 cm from the trachea, main bronchi, esophagus, aorta, aortic arch branches, pulmonary artery and the heart.

32998

76940

 

 

 

 

 


Malignant Non-Pulmonary Tumor(s) Metastatic to the Lung 

RFA may be considered medically necessary to treat malignant nonpulmonary tumor(s) metastatic to the lung that are no more than 3 cm in size when the following criteria are met: 

  • In order to preserve lung function when surgical resection or radiation treatment is likely to substantially worsen pulmonary status or the individual is not considered a surgical candidate; and
  • There is no evidence of extrapulmonary metastases; and
  • The tumor is located at least 1 cm from the trachea, main bronchi, esophagus, aorta, aortic arch branches, pulmonary artery and the heart; and
  • No more than three (3) tumors per lung should be ablated; and
  • Tumors should be amenable to complete ablation; and
  • Twelve (12) months should elapse before a repeat ablation is considered.

32998

76940

 

 

 

 

 


RFA is considered experimental/investigational and therefore non-covered as a technique for ablation of: 

  • Breast tumors;
  • Lung cancer not meeting the criteria above;
  • Renal cell cancer not meeting the criteria above;
  • Osteoid osteomas that can be managed with medical treatment;
  • Painful bony metastases as initial treatment; and
  • All other tumors outside the liver including, but not limited to:
    • the head and neck
    • thyroid
    • adrenal gland
    • ovary
    • pelvic/abdominal metastases of unspecified origin. 

The evidence is insufficient to determine the impact of the technology on health outcomes.

20982

76940

 

 

 

 

 


Related Policies

 

Refer to medical policy S-141, Radiofrequency Ablation (RFA) and Cryosurgery of Primary or Metastatic Liver Tumors, for additional information.

 


C34.00

C34.01

C34.02

C34.11

C34.12

C34.2

C34.31

C34.32

C34.81

C34.82

C34.91

C34.92

C40.00

C40.01

C40.02

C40.10

C40.11

C40.12

C40.20

C40.21

C40.22

C40.30

C64.1

C64.2

C78.01

C78.02

C79.01

C79.02

C79.51

C79.52

D16.01

D16.02

D16.11

D16.12

D16.21

D16.22

D16.31

D16.32

D16.4

D16.5

D16.6

D16.7

D16.8

D16.9

D41.00

D41.01

D41.02

 

 


Place of Service: Inpatient/Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business


Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

    Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.




    Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

    Discrimination is Against the Law
    The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.