| Effective Date:08/23/2004 |
Title:Cryoablation of Breast Lesions
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| Revision Date:01/04/2007
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Document:BI083:00
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| CPT Code(s):19105
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Public Statement
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Effective Date:
a)
This policy
will apply to all services performed on or after the above revision date which
will become the new effective date.
b)
For all
services referred to in this policy that were performed before the revision
date, contact customer service for the rules that would apply.
The treatment of breast lesions, whether benign or malignant, by cryoablation is
considered experimental/investigational, and is not covered.
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Medical Statement
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Cryoablation has been advocated as a treatment technique for both benign and malignant lesions in the breast. As of the date of this policy, there is insufficient evidence in the peer reviewed medical literature to establish either the safety or efficacy of this treatment method. Hayes gives it a rating of D. Codes Used In This BI: 19105 – Cryoablation of Breast Lesion
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Limits
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Intentially left empty
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Reference
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Intentially left empty
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Application to Products
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This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
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Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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