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Date Printed: June 26, 2017: 01:21 AM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

04-77260-23

Original Effective Date: 12/15/11

Reviewed: 12/06/12

Revised: 11/01/15

Subject: Microwave Thermotherapy for Breast Cancer

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
Other References Updates   Previous Version

DESCRIPTION:

Focused microwave phase array thermotherapy has been investigated as a type of heat therapy for treating either primary breast cancer in conjunction with lumpectomy in patients with early-stage breast cancer or as a cytoreductive technique in conjunction with preoperative chemotherapy in patients with advanced breast cancer. Microwave applicators are placed on either side of the compressed breast that, when activated, illuminate a large volume of breast tissue. A probe is placed within the breast to monitor the interstitial temperature. The technique is based on the preferential microwave heating that occurs in high-water content breast carcinoma compared to the surrounding lower water content healthy breast tissues. If successful, the microwave therapy could function similarly to the role of whole breast irradiation therapy after breast-conserving surgery, i.e., by destroying microscopic residual cancer cells in patients with locally advanced primary breast cancer; microwave thermotherapy may reduce the size of the tumor sufficiently to allow a less invasive surgical procedure to be performed.

Currently, no microwave thermotherapy device that is indicated for the treatment of breast cancer has received approval for marketing from the U.S. Food and Drug Administration (FDA).

POSITION STATEMENT:

BILLING/CODING INFORMATION:

The following codes may be used to describe balloon sinuplasty.

CPT Coding:

0301T

Destruction/reduction of malignant breast tumor with externally applied focused microwave, including interstitial placement of disposable catheter with combined temperature monitoring probe and microwave focusing sensocatheter under ultrasound thermotherapy guidance (investigational)

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline reviewed date.

DEFINITIONS:

Primary breast cancer: breast cancer which is confined to the breast and/or the surrounding area (e.g., lymph nodes under the arms).

RELATED GUIDELINES:

None applicable.

OTHER:

Other names used to report microwave thermotherapy for breast cancer:

Focused microwave thermotherapy (FMT)

Hyperthermia

Radiofrequency ablation

Thermal Therapy

Thermotherapy

REFERENCES:

  1. American Society of Breast Surgeons Position Statement on Ablative and Percutaneous Treatment of Breast Cancer, 04/24/02.
  2. Blue Cross Blue Shield Association Microwave Thermotherapy for Primary Breast Cancer Medical Policy 2.03.06, 02/10/11.
  3. Dooley WC, Vargas HI, Fenn AJ et al. Focused microwave thermotherapy for preoperative treatment of invasive breast cancer: a review of clinical studies. Annals of Surgical Oncology 2010; 17(4): 1076-1093.
  4. National Cancer Institute (NCI). Hyperthermia in Cancer Treatment Fact Sheet, 08/31/11.
  5. Vargas HI, Dooley WC, Gardner RA et al. Focused microwave phased array thermotherapy for ablation of early-stage breast cancer: results of thermal dose escalation. Annals of Surgical Oncology 2004; 11(2): 139-146.
  6. Vlastos G, Verkooijen HM. Minimally invasive approaches for diagnosis and treatment of early-stage breast cancer. Oncologist 2007; 12(1): 1-10.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 12/06/12.

GUIDELINE UPDATE INFORMATION:

12/15/11

New Medical Coverage Guideline.

01/15/13

Annual review; no change in position statement.

05/11/14

Revision: Program Exceptions section updated.

11/01/15

Revision: ICD-9 Codes deleted.

Date Printed: June 26, 2017: 01:21 AM