Coverage Policies

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)    Some non surgical treatment of liver cancers and metastases require pre-authorization.

2)    Several different forms of treatment are used to treat liver tumors that are not possible to treat with surgery.

All of the following procedures require pre-authorization with a diagnosis of liver cancer (C22.0 – C22.9, C78.7):

1. Percutaneous Ethanol Injection

Percutaneous ethanol injection (PEI) is considered medically necessary for the treatment of hepatocellular cancers (HCC) without extrahepatic spread.

1. Chemoembolization

Chemoembolization (CE, TACE) is considered medically necessary for any of the following:

1. For symptomatic treatment of functional neuroendocrine cancers (i.e., carcinoid tumors and pancreatic endocrine tumors) involving the liver. For carcinoid tumors, TACE is considered medically necessary only in persons who have failed systemic therapy with octreotide to control carcinoid syndrome (e.g., debilitating flushing, wheezing and diarrhea); or
2. For unresectable, primary HCC; or
3. As a bridge to transplant in patients with hepatocellular cancer where the intent is to prevent further tumor growth and to maintain a patient’s candidacy for liver transplant when  all of the following patient characteristics apply:

·      A single tumor less than 5cm or no more than 3 tumors each less than 3 cm in size, AND

·      Absence of extrahepatic disease or vascular invasion, AND

·      Child-Pugh score of either A or B.  See http://depts.washington.edu/uwhep/calculations/childspugh.htm

3.    Intra-hepatic Chemotherapy

Intra-hepatic chemotherapy (infusion) is considered medically necessary for members with liver metastases from colorectal cancer.

4.    Intra-hepatic Microspheres

Intra-hepatic microspheres (e.g., TheraSphere, MDS Nordion Inc.; SIR-Spheres, Sirtex Medical Inc., San Diego, CA) are considered medically necessary for any of the following:

1. For symptomatic treatment of functional neuroendocrine cancers (i.e., carcinoid tumors and pancreatic endocrine tumors) involving the liver. For carcinoid tumors, intrahepatic microspheres are considered medically necessary only in persons who have failed systemic therapy with octreotide to control carcinoid syndrome (e.g., debilitating flushing, wheezing and diarrhea); or
2. For unresectable, primary HCC;

i.      Tumor volume is < 50% of the target liver volume

ii.    Child-Pugh grade A (no ascites, bilirubin < 2 mg/dL, albumin > 3.5 g/dL, prothrombin time < 4 seconds over control, INR < 1.7, no encephalopathy)

iii.   There are no extrahepatic metastases

iv.   ECOG performance status of 0 – 2 (Ambulatory and capable of all self-care, but unable to carry out any work activities. Up and about more than 50% of waking hours.); or

C.   For unresectable liver tumors from primary colorectal cancer that has failed first line and second line standard chemotherapy.

i.      There is minimal or no extra-hepatic disease

ii.    Tumor volume is 50% or less of total liver volume

iii.   Bilirubin is less than 3 mg/dL

iv.   ECOG performance status of 0 – 2

Intra-hepatic microspheres are considered experimental and investigational for other indications.

1. Cryosurgery, Microwave, Radiofrequency or Radiopharmaceutical (such as yttrium-90) Ablation

Cryosurgery, microwave, or radiofrequency ablation is considered medically necessary for:

1. Isolated colorectal cancer liver metastases or isolated hepatocellular cancer who are not candidates for open surgical resection and who meet the following criteria:

i.      Ablation is being performed with curative not palliative intent.

ii.    Members must either have hepatic metastases from a colorectal primary cancer or have a hepatocellular cancer; and

iii.   Members must have isolated liver disease. Members with nodal or extra-hepatic systemic metastases are not considered candidates for these procedures; and

iv.   All tumors in the liver, as determined by preoperative imaging, would be potentially destroyed by cryotherapy, microwave, or radiofrequency ablation; and 

v.    Because open surgical resection is the preferred treatment, members must be unacceptable open surgical candidates due to the location or extent of the liver disease or due to co-morbid conditions such that the member is unable to tolerate an open surgical resection; and

vi.   Liver lesions must be 4 cm or less in diameter and occupy less than 50% of the liver parenchyma. Lesions larger than this may not be adequately treated by either procedure.

1. Unresectable neuroendocrine tumors metastatic to the liver.

Codes Used In This BI:

1.     Percutaneous ethanol injection (PEI) for other liver neoplasms is considered experimental and investigational when criteria are not met. There is inadequate information to document the effectiveness of PEI as an alternative to surgical resection for the treatment of hepatic metastases. 

2.     Combined radiofrequency ablation and PEI is considered experimental and investigational for the treatment of HCC.

3.     Chemoembolization is considered experimental and investigational for palliative treatment of liver metastases from other non-neuroendocrine primaries (e.g., colon cancer, melanoma, or unknown primaries) because there is inadequate evidence in the medical literature of the effectiveness of CE for these indications.

4.     Intra-hepatic chemotherapy is considered experimental and investigational for treatment of liver primaries or metastases from other primaries besides colorectal cancer.

5.      “One-shot” arterial chemotherapy for members with liver metastases from colorectal cancer is considered experimental and investigational.

6.     Transarterially administered gene therapy is considered experimental and investigational for primary and secondary liver malignancies.

7.     Drug-eluting beads trans-arterial chemoembolization are considered experimental and investigational for primary and liver-dominant metastatic disease of the liver.

8.     Cryosurgical, microwave, or radiofrequency ablation as a treatment of hepatic metastases from non-colonic primary cancers is considered experimental and investigational.

9.     Cryosurgical, microwave or radiofrequency ablation as a palliative treatment of either hepatic metastases from colorectal cancer or hepatocellular cancer is also considered experimental and investigational.

Chemoembolization (CE) involves the periodic injection of chemotherapy mixed with embolic material into selected branches of the hepatic arteries feeding liver tumors. CE has been successfully used as a palliative treatment of symptoms associated with functioning neuroendocrine tumors involving the liver.  The most common such tumor is the carcinoid tumor whose hormone production is associated with the carcinoid syndrome, characterized by debilitating flushing, wheezing, and diarrhea.  Pancreatic endocrine tumors that produce gastrin, insulin or other pancreatic hormones are unusual types of neuroendocrine tumors.  Pancreatic endocrine (i.e., islet cell) tumors must be distinguished from the more common pancreatic epithelial tumors that arise from the exocrine portion of the pancreas.

The prognosis for patients with unresectable hepatocellular carcinoma (HCC) tumors is extremely poor.  Even in the case of small nodular lesions detected by US screening, patients receiving no treatment showed a mean 3-year survival rate of 12%.  Among non-surgical options, percutaneous ethanol injection (PEI) can be considered the treatment of choice for patients with small HCC tumors.  Transcatheter arterial chemoembolization (TACE), most frequently performed by intra-arterially injecting an infusion of antineoplastic agents mixed with iodized oil (Lipiodol), has been extensively used in the treatment of large HCC tumors.  However, although massive tumor necrosis can be demonstrated in most cases, a complete necrosis of the tumor has rarely been achieved with TACE, since residual tumor can be found in a non-negligible number of the treated lesions.

TACE was found mostly effective in nodules less than 4 cm in diameter, with a thick tumor capsule. In fact, small, encapsulated HCC are almost completely fed by hepatic arterial blood and therefore highly responsive to hepatic arterial embolization.  On the contrary, in unencapsulated tumors or in tumors showing extracapsular invasion of neoplastic cells, TACE often fails to induce complete necrosis since tumor cells, either unimpeded by the absence of a capsule or spreading across the capsule itself, invade the adjacent liver parenchyma, thus obtaining additional blood supply from the sinusoidal portal system.

Large HCC lesions can be more effectively treated with combined TACE and PEI.  In fact, alcohol diffusion is easier after the occurrence of the necrotic changes produced by TACE, thus allowing the intranodular injection of larger amounts of ethanol.  Moreover, after arterial embolization, the normal wash-out of the injected ethanol is more difficult in the tumorous area, resulting in longer retention of the substance.  The combination of TACE and PEI seems to be a highly effective treatment for large HCC also in the instances when daughter nodules are associated with a main tumor.  The presence of the capsule significantly enhances the chances of success and should be considered an important requirement when selecting patients to be submitted to TACE and PEI.

According to available literature, chemoembolization (TACE) may be indicated for symptomatic treatment of functional neuroendocrine cancers (i.e., carcinoid tumors and pancreatic endocrine tumors) involving the liver, in persons with adequate hepatic function (bilirubin less than 2 mg/dl, absence of ascites; no portal vein occlusion; and tumor involvement of less than 65 % of liver).  For carcinoid tumors, TACE is indicated only in persons who have failed systemic therapy with octreotide to control carcinoid syndrome (e.g., debilitating flushing, wheezing, and diarrhea).  The safety and effectiveness of more than 4 TACE procedures is unknown. 

Percutaneous ethanol injection has been shown to be effective only in primary hepatocellular carcinoma with a limited number (fewer than 4) of small foci (less than 5 cm in diameter) and with no evidence of extrahepatic metastasis.  According to the medical literature, PEI is not suitable for persons with coagulopathy or ascites.

In a randomized controlled study, Brunello and colleagues (2008) compared PEI and RFA for the treatment of early HCC.  A total of 139 cirrhotic patients in Child-Pugh classes A/B with 1-3 nodes of HCC (diameter 15 to 30 mm), for a total of 177 lesions were included in this study.  Patients were randomized to receive RFA (n = 70) or PEI (n = 69).  The primary end-point was complete response (CR) 1 year after the percutaneous ablation of all HCC nodes identified at baseline.  Secondary end-points were: early (30 to 50 days) CR, complications, survival, and costs.  In an intention-to-treat analysis, 1-year CR was achieved in 46/70 (65.7 %) and in 25/69 (36.2 %) patients treated by RFA and PEI, respectively (p = 0.0005).  For lesions greater than 20 mm in diameter, there was a larger CR rate in the RFA-treated subjects (68.1 % versus 26.3 %).  An early CR was obtained in 67/70 (95.7 %) patients treated by RFA compared with 42/64 (65.6 %) patients treated by PEI (p = 0.0001).  Complications occurred in 10 and 12 patients treated by RFA and PEI, respectively.  The overall survival rate was not significantly different in the RFA versus PEI arm (adjusted hazard ratio = 0.88, 95 % CI: 0.50 to 1.53).  There was an incremental health-care cost of 8286 Euro for each additional patient successfully treated by RFA.  The authors concluded that the 1-year CR rate after percutaneous treatment of early HCC was significantly better with RFA than with PEI, but did not provide a clear survival advantage in cirrhotic patients.

Hepatic arterial infusion (HAI) of chemotherapy involves the use of an implanted subcutaneous pump to deliver continuous chemotherapy into the hepatic artery.  Controlled trials have shown that this therapy is associated with higher tumor response rates and this approach is considered a potentially curative treatment of patients with colorectal cancer (CRC) with isolated liver metastases. Other applications of intra-hepatic chemotherapy are unproven.

In a review on recent advances in transarterial therapy of primary and secondary liver malignancies, Kalva and colleagues (2008) stated that transarterially administered gene therapy holds promise but is still in the early stages of investigation.

The liver is the most common site of distant metastasis from colorectal cancer. About one-fourth of patients with liver metastases from colorectal cancer has no other sites of metastasis and can be treated with regional therapies directed toward their liver tumors. Based on a preponderance of uncontrolled studies for hepatic metastatic colorectal carcinoma, surgical resection offers the only potential for cure of selected patients with completely resected disease, with 5-year survival rates of 25% to 46%; however, the majority of patients with primary or metastatic malignancies confined to the liver are not candidates for resection because of tumor size, location, or multifocality or inadequate functional hepatic reserve. For the treatment of patients with non-resectable liver metastases, alternative local ablative therapeutic modalities have been developed. For most patients with spread of metastatic colorectal cancer beyond the liver, systemic chemotherapy rather than regional therapy is a more appropriate option.

Cryotherapy is an effective and precise technique for inducing tumor necrosis, but it is currently performed via laparotomy. Recent results suggest that ultrasound-guided radiofrequency thermal ablation may be an effective, minimally invasive technique for treating malignant hepatic tumors. Both interventional therapeutic techniques have been shown to result in a remarkable local tumor control rate with improved survival results for patients with liver metastases from colorectal cancer.

The National Institute for Clinical Excellence (NICE, 2004) guidance on radiofrequency ablation (RFA) for the treatment of colorectal metastases to the liver stated that: "Current evidence on the safety of radiofrequency ablation of colorectal metastases in the liver appears adequate.  However, the evidence of its effect on survival is not yet adequate to support the use of this procedure without special arrangements for consent and for audit or research". In patients who are not eligible for traditional surgery, RFA can be used to destroy liver tumors. However, existing evidence does not conclusively support the effectiveness of RFA in improving patient survival.

Jungraithmayr, et al. (2005) stated that local ablative procedures such as cryosurgery and thermo-ablation are increasingly employed as a supplement to liver resection for the treatment of primary and secondary liver tumors.  However, it is still unclear whether the survival time can be extended through local ablative procedures.  In this prospective study (n = 19), these investigators reported operative actions, complications and long-term follow-up of patients with malignant liver tumors undergoing cryotherapy.  Subjects underwent cryotherapy due to a non-resectable malignant liver tumor (17 subjects with metastases of a colon carcinoma, and 2 subjects with a hepatocellular carcinoma).  A total of 12 patients (63.2%) received cryotherapy only, and 7 patients (36.8%) received a combination of resection and cryotherapy.  The median follow-up period was 23 months.  The 30-day mortality was 0 %, and the rate of major complications was 21%.  After one year, 27.3% of the patients were still recurrence-free.  The recurrence rate for all tumors treated was 58.8%.  The median survival time for all patients was 21 months.  The 1- and 3-year survival rates were 62.5% and 15.8%, respectively.  The authors concluded that the mortality for cryotherapy is low, but there is a high rate of complications and long-term tumor control is insufficient.  If local ablative procedures of hepatic lesions are to be performed, not laparotomy but percutaneous, percutaneous thermoablation should be discussed as an alternative therapeutic measure.

Microwave energy can also be used to destroy liver neoplasms. Microwave ablation destroys tumor cells by heat, resulting in localized areas of necrosis and tissue destruction. Guidance from the National Institute for Health and Clinical Excellence (NICE, 2006) concluded that there is sufficient evidence of the safety and effectiveness of microwave ablation of hepatocellular carcinoma. This conclusion was based upon the results of nonrandomized controlled studies of microwave ablation of hepatocellular carcinoma that found similar outcomes to liver resection (Midorikawa, et al., 2005), percutaneous ethanol injection (Seki, et al., 1999), and radiofrequency ablation (Lu, et al., 2005). However, NICE (2007) found insufficient evidence of the safety and effectiveness of microwave ablation of colorectal cancer metastatic to the liver and other liver metastases. One small randomized controlled clinical trial (n = 30) found similar overall and disease free survival with liver resection and microwave ablation of liver metastases (Shibata, et al., 2000). Other uncontrolled case series reported similar results with microwave ablation of liver metastases (Liang, et al., 2003; Morikawa, et al., 2002).

Guidelines on neuroendocrine tumors from the National Comprehensive Cancer Network (NCCN, 2009) state that, for unresectable liver metastases from carcinoid tumors and islet cell tumors, locally ablative therapy is recommended.

Percutaneous Ethanol Injection

1. Büchner-Steudel P, Behl S, Fleig WE. Percutaneous ethanol injection or percutaneous acetic acid injection for hepatocellular carcinoma (Protocol for Cochrane Review). Cochrane Database Systematic Rev. 2007 ;( 3):CD003779. 
2. Masaki T, Morishita A, Kurokohchi K, Kuriyama S. Multidisciplinary treatment of patients with hepatocellular carcinoma. Expert Rev Anticancer Ther. 2006; 6(10):1377-1384.
3. Brunello F, Veltri A, Carucci P, et al. Radiofrequency ablation versus ethanol injection for early hepatocellular carcinoma: A randomized controlled trial. Scand J Gastroenterol. 2008; 43(6):727-735.
4. Wong SN, Lin CJ, Lin CC, et al. Combined percutaneous radiofrequency ablation and ethanol injection for hepatocellular carcinoma in high-risk locations. AJR Am J Roentgenol. 2008; 190(3):W187-W195.
5. Schoppmeyer K, Weis S, Mössner J, Fleig WE. Percutanous ethanol injection or percutaneous acetic acid injection for early hepatocellular carcinoma. Cochrane Database Syst Rev. 2009 ;( 3):CD006745.

Chemoembolization

1. Llovet JM, Real MI, Montaña X, et al. Arterial embolisation, or chemoembolisation versus symptomatic treatment in patients with unresectable hepatocellular carcinoma: A randomised controlled trial. Lancet. 2002; 359:1734-1739.
2. Ramsey DE, Kernagis LY, Soulen MC, Geschwind JF. Chemoembolization of hepatocellular carcinoma. J Vasc Interv Radiol. 2002; 13(9 Pt 2):S211-S221.
3. Oliveri RS, Gluud C. Transcatheter arterial embolisation and chemoembolisation for hepatocellular carcinoma (Protocol for Cochrane Review). Cochrane Database Systematic Rev. 2004 ;( 2):CD004787.
4. Llovet JM, Bruix J. Systematic review of randomized trials for unresectable hepatocellular carcinoma: Chemoembolization improves survival. Hepatology. 2003; 37(2):429-442.
5. Camma C, Schepis F, Orlando A, et al. Transarterial chemoembolization for unresectable hepatocellular carcinoma: Meta-analysis of randomized controlled trials. Radiology. 2002; 224(1):47-54. 
6. Marelli L, Stigliano R, and Triantos C, et al. Transarterial therapy for hepatocellular carcinoma: Which technique is more effective? A systematic review of cohort and randomized studies. Cardiovasc Intervent Radiol. 2007; 30(1):6-25.
7. Pleguezuelo M, Marelli L, Misseri M, et al. TACE versus TAE as therapy for hepatocellular carcinoma. Expert Rev Anticancer Ther. 2008; 8(10):1623-1641.

Intra-hepatic Chemotherapy (Infusion) for Liver Malignancies

1. Okada S. Chemotherapy in hepatocellular carcinoma. Hepatogastroenterology. 1998; 45 (Suppl 3):1259-1263.
2. Sakai Y, Izumi N, Tazawa J, et al. Treatment for advanced hepatocellular carcinoma by transarterial chemotherapy using reservoirs or one-shot arterial chemotherapy. J Chemother. 1997; 9(5):347-351.
3. Soga K, Nomoto M, Ichida T, et al. Clinical evaluation of Transcatheter arterial embolization and one-shot chemotherapy in hepatocellular carcinoma. Hepatogastroenterology. 1988; 35(3):116-120.
4. ES-Y, Chow PK-H, Tai B-C, et al. Neoadjuvant and adjuvant therapy for operable hepatocellular carcinoma. Cochrane Database Systematic Rev. 1999 ;( 3):CD001199.
5. Nordlinger B, Rougier P. Nonsurgical methods for liver metastases including cryotherapy, radiofrequency ablation, and infusional treatment: What`s new in 2001? Curr Opin Oncol. 2002; 14(4):420-423.
6. Mocellin S, Pilati P, Lise M, Nitti D. Meta-analysis of hepatic arterial infusion for unresectable liver metastases from colorectal cancer: The end of an era? J Clin Oncol. 2007; 25(35):5649-5654.
7. Kalva SP, Thabet A, Wicky S. Recent advances in transarterial therapy of primary and secondary liver malignancies. Radiographic. 2008; 28(1):101-117.

Intrahepatic Microspheres (TheraSphere, SIR-Sphere)

1. Sato K, Lewandowski RJ, Bui JT, et al. Treatment of unresectable primary and metastatic liver cancer with yttrium-90 microspheres (TheraSphere): Assessment of hepatic arterial embolization. Cardiovasc Intervent Radiol. 2006; 29(4):522-529.
2. Kulik LM, Atassi B, van Holsbeeck L, et al. Yttrium-90 microspheres (TheraSphere) treatment of unresectable hepatocellular carcinoma: Down staging to resection, RFA, and bridge to transplantation. J Surg Oncol. 2006; 94(7):572-586.
3. Allison C. Yttrium-90 microspheres (TheraSphere® and SIR-Spheres®) for the treatment of unresectable hepatocellular carcinoma. Issues in Emerging Health Technologies Issue 102. Ottawa, ON: Canadian Agency for Drugs and Technologies in Health; September 2007. Available at: http://www.cadth.ca/media/pdf/E0038_TheraSphere_cetap_e.pdf. Accessed March 28, 2011.
4. Sato KT, Lewandowski RJ, Mulcahy MF, et al. Unresectable chemo refractory liver metastases: Radio embolization with 90Y microspheres--safety, efficacy, and survival. Radiology. 2008; 247(2):507-515.
5. National Comprehensive Cancer Network (NCCN). Neuroendocrine tumors. NCCN Clinical Practice Guidelines in Oncology. V.2.2009. Fort Washington, PA: NCCN; 2009.
6. Vente MA, Wondergem M, van der Tweel I, et al. Yttrium-90 microsphere radio embolization for the treatment of liver malignancies: A structured meta-analysis. Eur Radiol. 2009; 19(4):951-959.
7. Townsend A, Price T, Karapetis C. Selective internal radiation therapy for liver metastases from colorectal cancer. Cochrane Database Syst Rev. 2009 ;( 4):CD007045.
8. Tice JA. Selective internal radiation therapy or radio embolization for inoperable liver metastases from colorectal cancer. A Technology Assessment. San Francisco, CA: California Technology Assessment Forum (CTAF); February 17, 2010.

Drug-Eluting Beads Trans-Arterial Chemoembolization

1. Poon RT, Tso WK, Pang RW, et al. A phase I/II trial of chemoembolization for hepatocellular carcinoma using a novel intra-arterial drug-eluting bead. Clin Gastroenterol Hepatol. 2007; 5(9):1100-1108.
2. Malagari K, Chatzimichael K, Alexopoulou E, et al. Transarterial chemoembolization of unresectable hepatocellular carcinoma with drug eluting beads: Results of an open-label study of 62 patients. Cardiovasc Intervent Radiol. 2008; 31(2):269-280.
3. Stewart C, Martin RCG. Drug-eluting bead therapy in primary and metastatic disease of the liver. HPB. 2009; 11(7):541-550.
4. Fiorentini G, Aliberti C, Del Conte A, et al. Intra-arterial hepatic chemoembolization (TACE) of liver metastases from ocular melanoma with slow-release irinotecan-eluting beads. Early results of a phase II clinical study. In Vivo. 2009; 23(1):131-137.
5. Martin RC, Robbins K, Tomalty D, et al. Transarterial chemoembolisation (TACE) using irinotecan-loaded beads for the treatment of unresectable metastases to the liver in patients with colorectal cancer: An interim report. World J Surg Oncol. 2009; 7:80.
6. Guiu B, Colin C, Cercueil JP, et al. Pilot study of transarterial chemoembolization with pirarubicin and amiodarone for unresectable hepatocellular carcinoma. Am J Clin Oncol. 2009; 32(3):238-244.
7. Tokh M, Nugent FW, Molgaard C, et al. Transarterial chemoembolization (TACE) with drug-eluting beads (DEB) in hepatocellular carcinoma (HCC): A large single-institution experience. 2010 Gastrointestinal Cancers Symposium, Abstract No. 248. Available at: http://www.asco.org/ASCOv2/Meetings/Abstracts?&vmview=abst_detail_view&confID=72&abstractID=1818. Accessed March 28, 2011.

Ablation

1. Seki T, Wakabayashi M, Nakagawa T, et al. Percutaneous microwave coagulation therapy for patients with small hepatocellular carcinoma: Comparison with percutaneous ethanol injection therapy. Cancer. 1999; 85:1694–1702.
2. Shibata T, Iimuro Y, Yamamoto Y, et al. Small hepatocellular carcinoma: Comparison of radio-frequency ablation and percutaneous microwave coagulation therapy. Radiology. 2002; 223:331–337.
3. Liang P, Dong B, Yu X, et al. Prognostic factors for survival in patients with hepatocellular carcinoma after percutaneous microwave ablation. Radiology. 2005; 235:299–307.
4. Ajisaka H, Miwa K. Acute respiratory distress syndrome is a serious complication of microwave coagulation therapy for liver tumors. Am J Surg. 2005; 189:730–733.
5. National Institute for Health and Clinical Excellence (NICE). Microwave ablation for treatment of metastases in the liver. Interventional Procedure Guidance 220. London, UK: NICE; May 2007.
6. National Institute for Health and Clinical Excellence (NICE). Microwave ablation of hepatocellular carcinoma. Interventional Procedure Guidance 214. London, UK: NICE; March 2007.
7. National Comprehensive Cancer Network (NCCN). Hepatobiliary cancers. NCCN Clinical Practice Guidelines in Oncology. V.1.2007. Jenkintown, PA: NCCN; 2007.
8. National Comprehensive Cancer Network (NCCN). Colon cancer. NCCN Clinical Practice Guidelines in Oncology. V.2.2007. Jenkintown, PA: NCCN; 2007.
9. Kornprat P, Jarnagin WR, DeMatteo RP, et al. Role of intraoperative thermoablation combined with resection in the treatment of hepatic metastasis from colorectal cancer. Arch Surg. 2007; 142(11):1087-1092.
10. Siperstein AE, Berber E, Ballem N, Parikh RT. Survival after radiofrequency ablation of colorectal liver metastases: 10-year experience. Ann Surg. 2007; 246(4):559-565; discussion 565-567.
11. Al-asfoor A, Fedorowicz Z, Lodge M. Resection versus no intervention or other surgical interventions for colorectal cancer liver metastases. Cochrane Database Syst Rev. 2008 :( 2):CD006039.
12. Brunello F, Veltri A, Carucci P, et al. Radiofrequency ablation versus ethanol injection for early hepatocellular carcinoma: A randomized controlled trial. Scand J Gastroenterol. 2008; 43(6):727-735.
13. Garrean S, Hering J, Saied A, et al. Radiofrequency ablation of primary and metastatic liver tumors: A critical review of the literature. Am J Surg. 2008; 195(4):508-520.
14. Lau WY, Lai EC. The current role of radiofrequency ablation in the management of hepatocellular carcinoma: A systematic review. Ann Surg. 2009; 249(1):20-25.
15. National Comprehensive Cancer Network (NCCN). Neuroendocrine tumors. NCCN Clinical Practice Guidelines in Oncology v.2.2009. Fort Washington, PA: NCCN; 2009.
16. Stang A, Fischbach R, Teichmann W, et al. A systematic review on the clinical benefit and role of radiofrequency ablation as treatment of colorectal liver metastases. Eur J Cancer. 2009; 45(10):1748-1756.
17. Wong SL, Mangu PB, Choti MA, et al. American Society of Clinical Oncology 2009 clinical evidence review on radiofrequency ablation of hepatic metastases from colorectal cancer. J Clin Oncol. 2010; 28(3):493-508.

This policy applies to all health plans and products 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) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.