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Date Printed: August 21, 2017: 07:54 PM

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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.

02-40000-23

Original Effective Date: 02/15/04

Reviewed: 03/25/10

Revised: 11/01/15

Subject: Radiofrequency Ablation of Liver Tumors

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    
           

DESCRIPTION:

Radiofrequency ablation (RFA) and cryosurgical ablation (CSA) have been investigated as a treatment for unresectable hepatic (liver) tumors. This coverage guideline will address radiofrequency ablation of liver tumors.

Radiofrequency ablation involves inserting an electrode into the center of the tumor delivering alternating current from a generator operated at 50 to 200 watts of power. Protein denaturation and coagulation is the ultimate cause of cell death. Radiofrequency ablation may be performed percutaneously, laparoscopically, or as an open procedure.

Hepatic tumors can arise either as primary liver cancer or by metastasis to the liver from other tissues. The liver is the most common site of metastasis for neoplasms disseminated via blood circulation. Local therapy for hepatic metastasis is indicated only when there is no extra-hepatic disease. Presently, surgical resection with adequate margins, or liver transplantation are the only treatments available with demonstrated curative potential. The majority of hepatic tumors are unresectable at diagnosis due either to their anatomic location, size, number of lesions, or underlying liver reserve.

POSITION STATEMENT:

Radiofrequency ablation of tumors in the liver meets the definition of medical necessity for the treatment of primary hepatic tumors or metastatic tumors when the following criteria are met:

BILLING/CODING INFORMATION:

CPT Coding:

47370

Laparoscopy, surgical, ablation or 1 or more liver tumor(s); radiofrequency

47380

Ablation, open, or 1 or more liver tumor(s); radiofrequency

47382

Ablation, 1 or more liver tumor(s), percutaneous, radiofrequency

76940

Ultrasound guidance for, and monitoring of parenchymal tissue ablation

77013

Computerized tomography guidance for, and monitoring of parenchymal tissue ablation

77022

Magnetic resonance guidance for, and monitoring of parenchymal tissue ablation

ICD-10 Diagnoses Codes That Support Medical Necessity: (Effective 10/01/15)

C22.0

Liver cell carcinoma

C22.1

Intrahepatic bile duct carcinoma

C22.2

Hepatoblastoma

C22.7

Other specified carcinomas of liver

C22.8

Malignant neoplasm of liver, primary, unspecified as to type

C22.9

Malignant neoplasm of liver, not specified as primary or secondary

C78.7

Secondary malignant neoplasm of liver and intrahepatic bile duct

D01.5

Carcinoma in situ of liver, gallbladder and bile ducts

D37.6

Neoplasm of uncertain behavior of liver, gallbladder and bile ducts

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:

Extra-hepatic metastases: cancer that has spread from its original location to other sites within the body, other than the liver.

Hepatic metastases: cancer that has spread from its original location in the body to the liver.

Primary hepatocellular cancer: a cancer that originates within liver cells, as opposed to having spread from other organs; malignant hepatoma.

Radiofrequency ablation (RFA): a surgical procedure where cancerous or diseased cells are destroyed using heat produced by high-frequency radiowaves.

Unresectable: a property of a tumor where it is unable to be removed surgically.

RELATED GUIDELINES:

Cryoablation of Liver Tumors, 02-40000-22
Cryosurgical Ablation of the Prostate (CSAP), 02-54000-14

Cryosurgical Ablation of Solid Tumors Other Than Liver or Prostate Tumors, 02-99221-12

Radiofrequency Ablation of Solid Tumors Other Than Liver Tumors, 02-99221-13

OTHER:

None applicable.

REFERENCES:

  1. Blue Cross Blue Shield Association Technology Evaluation Center (TEC) Assessment. Radiofrequency Ablation of Unresectable Hepatic Tumors, TEC Assessments 2003, Volume 18, Tab No. 13.
  2. Blue Cross Blue Shield Association. Medical Policy Reference Manual. 7.01.91 Radiofrequency Ablation of Primary or Metastatic Liver Tumors, 03/11/10.
  3. Clinical Trials.gov. Study of Percutaneous Radiofrequency Ablation (RFA) of Hepatocellular Carcinoma in Cirrhotic Patients. Phase I trial. Identifier NCT00399958 Verified by M.D. Anderson Cancer Center
  4. ClinicalTrials.gov. Radiofrequency Ablation in Treating Patients With Unresectable Primary or Metastatic Liver Cancer, Phase II trial. Identifier NCT00019604. Verified by National Cancer Institute, 01/07.
  5. ClinicalTrials.gov. Radiofrequency Ablation in Treating Patients With Liver Cancer and Cirrhosis. Phase II trial. Identifier NCT00132041. (Verified by National Cancer Institute, 12/06).
  6. ECRI Health Technology Assessment, “Radiofrequency Ablation for the Treatment of Primary and Metastatic Liver Cancer”, (04/03)
  7. Galandi D, Antes G. Radiofrequency thermal ablation versus other interventions for hepatocellular carcinoma. Cochrane Database of Systematic Reviews 2004, Issue 2. Art. No.: CD003046. DOI: 10.1002/14651858. CD003046.pub2.
  8. Hayes Medical Technology Directory, Radiofrequency Ablation for Primary and Metastatic Cancers Of The Liver (04/04; update report 10/02/07).
  9. National Cancer Institute, “Adult Primary Liver Cancer (PDQ®): Treatment”, (10/31/08).
  10. United Network for Organ Sharing (UNOS) policies; accessed at website 03/10.
  11. Yun Ku Cho, Jae Kyun Kim, Mi Young Kim, Hyunchul Rhim, Joon Koo Han. Systematic review of randomized trials for hepatocellular carcinoma treated with percutaneous ablation therapies. DOI: 10.1002/hep.22648.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 03/25/10.

GUIDELINE UPDATE INFORMATION:

02/15/04

Reviewed Radiofrequency/Cryoablation of Liver Tumors MCG #02-40000-22 and separated into two different policies Radiofrequency Ablation of Liver Tumors and Cryosurgical Ablation of Liver Tumors; coverage statement changed for radiofrequency ablation of liver tumors.

06/15/04

Revision consisting of removal of ICD-9 diagnosis code for benign liver tumors.

05/15/05

Scheduled review; no change in coverage statement.

03/15/06

Scheduled review; expand coverage to include metastatic liver tumors.

03/15/07

Scheduled review; no change in coverage statement; update coding section and references.

06/15/07

Reformatted guideline.

03/15/08

Scheduled review; no change in position statement. Update references.

04/15/09

Scheduled review; no change in position statement. Update references.

01/01/10

Annual HCPCS coding update: revise descriptors for CPT codes 47370, 47380, & 47382.

04/15/10

Annual review; no change in position statement. References updated.

10/15/10

Revision; related ICD-10 codes added.

05/11/14

Revision: Program Exceptions section updated.

11/01/15

Revision: ICD-9 Codes deleted.

Date Printed: August 21, 2017: 07:54 PM