HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
S-141-016
Topic:
Radiofrequency Ablation (RFA) and Cryosurgery of Primary or Metastatic Liver Tumors
Section:
Surgery
Effective Date:
September 10, 2018
Issued Date:
March 11, 2019
Last Revision Date:
August 2018
Annual Review:
August 2018
 
 

Radiofrequency ablation (RFA) is a procedure in which a probe is inserted into the center of a tumor and heated locally by a high frequency, alternating current that flows from electrodes. The local heat treats the tissue adjacent to the probe, resulting in a 3-5 cm sphere of dead tissue. The cells killed by RFA are not removed but are gradually replaced by fibrosis and scar tissue. RFA may be performed percutaneously, laparoscopically, or as an open procedure.

Cryosurgical ablation involves the freezing of target tissues, most often by inserting a probe into the tumor where coolant is circulated. Cryosurgical ablation can be performed as an open surgical technique or percutaneously or laparoscopically, typically with ultrasound guidance.

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

RFA of primary or metastatic hepatocellular carcinoma (HCC) may be considered medically necessary when ANY of following are met: 

  • There are no more than three (3) nodules and all tumor foci can be adequately treated; or
  • As a bridge to transplant when ALL of the following criteria have been met:
    • Preserved liver function defined as Child-Pugh Class A or B; and
    • Single  tumors less than or equal to 6.5 cm in diameter, or no more than three (3) lesions less than or equal to 4.5 cm in diameter, and total tumor diameter less than or equal to 8 cm ; and
    • No evidence of extra-hepatic metastases; and
    • No evidence of severe renal function impairment; and
    • No evidence of portal vein occlusion; or
  • Primary or metastatic treatment of hepatic metastases 5 cm or less in diameter from colorectal cancer in the absence of extrahepatic metastatic disease when all tumor foci can be adequately treated; or
  • Treatment of hepatic metastases from neuroendocrine tumors in patients with symptomatic disease when systemic therapy has failed to control symptoms; or
  • As a repeat procedure when at least six (6) months have elapsed since the prior surgical resection or ablation.

RFA for hepatic metastasis is considered experimental/investigational for the following:

  • Hepatic metastases from colorectal cancer or neuroendocrine tumors that do not meet the criteria above; and
  • Hepatic metastases from other types of cancer with the exception of colorectal cancer or neuroendocrine tumors.

RFA of liver tumors is considered experimental/investigational for all other indications due to the lack of scientific evidence to support efficacy and safety and therefore non-covered.

47370

47380

47382

76940

 

 

 




Cryosurgery of the liver, using a FDA-approved cryosurgical device, may be considered medically necessary for select individuals with unresectable liver tumors or for patients whose liver tumors are not totally resectable when ALL of the following criteria are met:

  • Proven primary or secondary malignant tumor by biopsy, tumor markers, MRI, CT scan or ultrasound; and
  • The lesion(s) must be unresectable, whether on the basis of size, location, (proximity to major structures) bilobar involvement, or underlying liver disease (such as cirrhosis); and
  • For individuals with metastatic disease there must be no residual tumor at the primary site; and
  • There must be no evidence of extrahepatic malignancy; and 
  • All visible tumors (visible by imaging study including intraoperative ultrasound) must be eradicable; and
  • Lesion measures no more than 4 cm in diameter; and
  • Lesions must be either a primary hepatocellular carcinoma or hepatic metastases from either primary colorectal cancer or neuroendocrine cancer. 

The following uses of cryosurgery of the liver are considered experimental/investigational:

  • When policy criteria have not been met; or
  • Metastatic lesions of the liver are from tumor primaries other than colorectal or neuroendocrine cancer.

Cryosurgery for liver tumors is considered experimental/investigational for all other indications due to the lack of scientific evidence to support efficacy and safety and is therefore non-covered.

47371

47381

47383

76940

 

 

 




Related Policies

Refer to medical policy S-137 Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors for additional information. 


Covered Diagnosis Codes for Procedure Codes: 47370, 47380, 47382, 47371, 47381, 47383

C22.0

C22.2

C22.3

C22.4

C22.7

C22.8

C22.9

C78.7

D01.5

D37.6

 

 

 

 

 



Place of Service: Inpatient/Outpatient

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

RFA and Cryosurgery of Primary or Metastatic 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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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.

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  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
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    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.

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    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)

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