HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
S-137-006
Topic:
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors
Section:
Surgery
Effective Date:
September 17, 2018
Issued Date:
March 11, 2019
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

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 individual with significantly impaired renal function (i.e., the individual 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
    • Ovary
    • Pelvic/abdominal metastases of unspecified origin. 

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

20982

32998

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

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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



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