Medical Policy
Effective Date:01/01/2007 Title:Radiofrequency Ablation of Tumors
Revision Date:07/01/2020 Document:BI186:00
CPT Code(s):20982, 32998, 50592, 53852, 0600T, 0601T
Public Statement

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.

  1. Radiofrequency ablation requires pre-authorization, except for radiofrequency ablation of the prostate for benign prostatic enlargement.
  2. Radiofrequency ablation for plantar fasciitis is considered experimental/investigational and not covered.  Please see BI293 for additional information.
  3. Radiofrequency ablation of tumors involves insertion of an electrode into a lesion. Radiofrequency energy emitted through the electrode generates heat to kill abnormal tissue.
  4. This policy covers radiofrequency ablation for tumors other than primary or secondary liver tumors.  For information regarding liver tumor treatment, see BI301.
  5. NanoKnife tumor ablation (irreversible electroporation) is considered experimental/investigational and is not covered.
Medical Statement
  1. Percutaneous radiofrequency ablation is considered medically necessary for treatment of osteoid osteoma, as a less invasive alternative to surgical resection of the tumor. (D16.00-D16.9) Hayes B.
  2. Radiofrequency ablation is considered medically necessary as an alternative to surgical (cold knife) resection for debulking of primary and metastatic malignant neoplasms of the lung (C34.00-C34.92) or kidney (C64.1-C64.9).
  3. Radiofrequency ablation is considered medically necessary for removal of primary or metastatic malignant neoplasms of the lung (C34.00-C34.92) or kidney (C64.1-C64.9), when removal of the neoplasm may be curative, and the member is unable to tolerate surgical resection.
  4. Radiofrequency ablation (Transurethral needle ablation (TUNA) for the treatment of benign prostate hypertrophy (BPH) is considered medically necessary for members with benign prostatic hypertrophy (N40.1, N40.3) as alternatives to transurethral resection of the prostate.
  5. Radiofrequency ablation of varicose veins is covered in the policy on varicose veins (BI 093).
  6. Radiofrequency ablation is considered medically necessary for lesions of Barrett’s Esophagus showing dysplasia (K22.710-K22.719).

 

Codes Used In This BI:

 

20982             Ablation, bone tumor, radiofrequency

32998             Ablation therapy, pulmonary tumors, radiofrequency

50592             Ablation, renal tumors, percutaneous, radiofrequency

53852             Prostatic radiofrequency thermotherapy

0600T             Ablation, irreversible electroporation; 1 or more tumors per  organ,including imaging guidance, when performed, percutaneous

(new code 7/1/2020): E/I

0601T             Ablation, irreversible electroporation; 1 or more tumors, including fluoroscopic and ultrasound guidance, when performed, open

(new code 7/1/2020): E/I
Limits

1.    Radiofrequency ablation is considered experimental and investigational for curative treatment of primary or metastatic malignant neoplasms in persons who are able to tolerate surgical resection because the effectiveness of radiofrequency tumor ablation in improving clinical outcomes has not been established. Hayes D.

2.    Radiofrequency ablation of plantar fasciitis is considered experimental/investigative see BI293.

3.    NanoKnife (irreversible electroporation) tumor ablation is considered experimental/investigational and is not covered (Hayes D2).
Reference
  1. National Institute for Clinical Excellence (NICE). Percutaneous radiofrequency ablation of renal cancer. Interventional Procedure Consultation Document. London, UK: NICE; January 2004. Available at: http://www.nice.org.uk/article.asp?a=98417. Accessed January 6, 2004.
  2. National Institute for Clinical Excellence. Computed tomography-guided thermocoagulation of osteoid osteoma. Interventional Procedure Consultation Document. London, UK: NICE; December 2003. Available at:http://www.nice.org.uk/cms/htm/default/en/
    IP_221/ip221consultation/article.aspx. Accessed February 5, 2004.
  3. Cantwell CP, Obyrne J, Eustace S. Current trends in treatment of osteoid osteoma with an emphasis on radiofrequency ablation. Eur Radiol. 2004; 14(4):607-617.
  4. Mahnken AH, Gunther RW, Tacke J. Radiofrequency ablation of renal tumors. Eur Radiol. 2004; 14(8):1449-1455.
  5. Hinshaw JL, Lee FT Jr. Image-guided ablation of renal cell carcinoma. Magn Reson Imaging Clin N Am. 2004; 12(3):429-447, vi.
  6. Posteraro AF, Dupuy DE, Mayo-Smith WW. Radiofrequency ablation of bony metastatic disease. Clin Radiol. 2004; 59(9):803-811.
  7. Le QT, Petrik DW. Nonsurgical therapy for stages I and II non-small cell lung cancer. Hematol Oncol Clin North Am. 2005; 19(2):237-261, v-vi.
  8. Stamatis G. Operative and interventional therapy of lung metastases. MMW Fortschr Med. 2005; 147(1-2):25-26, 28-29.
  9. de Baere T. Radiofrequency in cancerology. Bull Cancer. 2005; 92(1):65-74.
  10. Feagins LA, Souza RF. Molecular targets for treatment of Barrett`s esophagus. Dis Esophagus. 2005; 18(2):75-86.
  11. Johnston MH. Technology insight: Ablative techniques for Barrett`s esophagus--current and emerging trends. Nat Clin Pract Oncol. 2005; 2(8):323-330.
  12. Yeh RW, Triadafilopoulos G. Endoscopic therapy for Barrett`s esophagus. Gastrointestinal Endosc Clin N Am. 2005; 15(3):377-397, vii.
  13. Shaheen NJ. Advances in Barrett`s esophagus and esophageal adenocarcinoma. Gastroenterology. 2005; 128(6):1554-1566.
  14. Pedrazzani C, Catalano F, Festini M, et al. Endoscopic ablation of Barrett`s esophagus using high power setting argon plasma coagulation: A prospective study. World J Gastroenterology. 2005; 11(12):1872-1875.
  15. Hage M, Siersema PD, Vissers KJ, et al. Molecular evaluation of ablative therapy of Barrett`s oesophagus. J Pathol. 2005; 205(1):57-64.
  16. Wolfsen HC. Endoprevention of esophageal cancer: Endoscopic ablation of Barrett`s metaplasia and dysplasia. Expert Rev Med Devices. 2005; 2(6):713-723.
  17. Ramon J, Lynch TH, Eardley I, et al. Transurethral needle ablation of the prostate for the treatment of benign prostate hyperplasia: A collaborative multicenter study. Br J Urol. 1997; 80(1):128-134.
  18. Blute ML, Tomera KM, Hellerstein DK, et al. Transurethral microwave thermotherapy for management of benign prostatic hyperplasia. Results of the United States Prostatron cooperative study. J Urol. 1993; 150(5 Pt 2):1591-1596.
  19. Bdesha AS, Bunce CJ, Kelleher JP, et al. Transurethral microwave treatment for benign prostatic hypertrophy. A randomized controlled trial. BMJ. 1993; 306(6888):1293-1296.
  20. de la Rosette JJ, de Wildt MJ, Alivizatos G, et al. Transurethral microwave thermotherapy (TUMT) in benign prostatic hyperplasia: Placebo versus TUMT. Urology. 1994; 44(1):58-63.
  21. Ogden CW, Reddy P, Johnson H, et al. Sham versus transurethral microwave thermotherapy in patients with symptoms of benign prostatic bladder outflow obstruction. Lancet. 1993; 341(8836):14-17.
  22. Goldfarb B, Bartkiw T, Trachtenberg J. Microwave therapy of benign prostatic hyperplasia. Urol Clinics North Am. 1995; 22(2):431-439.
  23. Djavan B, Madersbacher S, Klingler HC, et al. Outcome analysis of minimally invasive treatments for benign prostatic hyperplasia. Tech Urol. 1999; 5(1):12-20.
  24. National Institute for Clinical Excellence (NICE).  Transurethral radiofrequency needle ablation of the prostate.  Interventional Procedure Guidance 15.  London, UK: NICE; October 2003.  Available at: http://www.nice.org.uk/guidance/IPG15
  25. National Institute for Clinical Excellence (NICE). Radiofrequency ablation of hepatocellular carcinoma. Interventional Procedure Guidance 2.  London, UK: NICE; July 2003.  Available at: http://www.nice.org.uk/page.aspx?o=79379
  26. National Institute for Clinical Excellence (NICE).  Radiofrequency ablation for the treatment of colorectal metastases in the liver.  Interventional Procedure Consultation Document.  London, UK: NICE; January 2004.  Available at: http://www.nice.org.uk/article.asp?a=98463
  27. Nicholas J Shaheen et al, Radiofrequency ablation in Barrett’s Esophagus with Dysplasia: NEJM May 28, 2009 Number 22 pp 2277-2288.
  28. Shah DR, Green S, et al. Current oncologic applications of radiofrequency ablation therapies.  World J Gastro Oncol 2013; 5(4):71-80.
  29. Schneider T, Heussel CP, et al.  Thermal ablation of malignant lung tumors.  Dtsch Arztebl Int 2013; 110(22): 394-400
  30. Kim SD, Yoon SG, et al.  Radiofrequency ablation of renal tumors:  four year follow up results in 47 patients.  Korean J Radiol 2012; 13(5):625-633.
Application to Products
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.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.