Print

Date Printed: May 27, 2018: 07:34 PM

Private Property of Blue Cross and Blue Shield of Florida.
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.

02-99221-13

Original Effective Date: 03/15/04

Reviewed: 10/31/17

Revised 01/01/18

Subject: Radiofrequency Ablation of Solid Tumors Other Than 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:

In radiofrequency ablation (RFA), a probe is inserted into the center of a tumor and the noninsulated electrodes, which are shaped like prongs, are projected into the tumor; heat is then generated locally by a high-frequency, alternating current through the electrodes. The local heat treats the tissue adjacent to the probe, resulting in a 3- to 5.5-cm sphere of dead tissue. The cells killed by RFA are not removed but are gradually replaced by fibrosis and scar tissue. If there is local recurrence, it occurs at the edge and, in some cases, may be retreated. RFA may be performed percutaneously, laparoscopically, or as an open procedure.

Potential complications associated with RFA include those caused by heat damage to normal tissue adjacent to the tumor (e.g., intestinal damage during RFA of kidney), structural damage along the probe track (e.g., pneumothorax as a consequence of procedures on the lung), or secondary tumors, if cells seed during probe removal.

Ablation systems are approved by the Food and Drug Administration (FDA) under the 510(k) process as a Class II electrosurgical cutting and coagulation device and accessories (e.g., Valleylab Cool-tip™ RF Ablation System, 2006). The Valleylab Cool-tip RF System (generator and accessories) is intended for the use in percutaneous, laparoscopic, intraoperative coagulation and ablation of tissue, such as partial or complete ablation of non-resectable liver lesions and osteoid osteoma tumors within bone.

POSITION STATEMENT:

Note: For radiofrequency ablation of liver tumors, refer to Radiofrequency Ablation of Liver Tumors, 02-40000-23.

Radiofrequency ablation (RFA) meets the definition of medical necessity for the following indications:

Radiofrequency ablation (RFA) is considered experimental or investigational, there is insufficient clinical evidence to support the use of RFA for all other indications, including but not limited to:

For all other tumors outside the liver, the available evidence is insufficient to permit conclusions on net health outcomes of RFA.

BILLING/CODING INFORMATION:

CPT Coding:

20982

Ablation therapy for reduction or eradication of 1 or more bone tumors (e.g., metastasis), including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; radiofrequency

32998

Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, including imaging guidance when performed, unilateral; radiofrequency

50542

Laparoscopy, surgical; ablation of renal mass lesion(s)

50592

Ablation, one or more renal tumor(s), percutaneous, unilateral, radiofrequency

76940

Ultrasound guidance for, and monitoring of, tissue ablation

Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, including imaging guidance when performed, unilateral; radiofrequency

LOINC Codes:

The following information may be required documentation to support medical necessity: Physician history and physical, initial assessment, procedure note, visit note.

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician Initial Assessment

18736-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician procedure note

11505-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Attending physician visit note

18733-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

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:

Ablation: removal of a body part or destruction of its function.

Osteoid osteomas: benign tumors of the bone typically seen in children and young adults. They cause inflammation, local effects on normal tissue from tumor expansion, and secondary effects and complications (e.g., scoliosis, osteoarthritis).

Radiofrequency ablation (RFA): uses high-energy radio waves for treatment. A thin, needle-like probe temporarily placed into the tumor releases these radio waves. Placement of the probe is accurately guided by ultrasound or CT scans. The probe releases high frequency alternating current that creates frictional heating and destroys the cancer cells.

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

RELATED GUIDELINES:

Radiofrequency Ablation of Liver Tumors, 02-40000-23

OTHER:

None applicable.

REFERENCES:

  1. American College of Radiology. ACR Appropriateness Criteria – Nonsurgical Treatment for Non-Small-Cell Lung Cancer: Good Performance Status/Definitive Intent. Last reviewed 2010.
  2. American Society of Clinical Oncology. “Percutaneous radiofrequency ablation of lung tumours: Results in first 100 consecutive patients.”Abstract No: 7714. Citation: Journal of Clinical Oncology, 2007 ASCO Annual Meeting Proceedings Part I. Vol 25, No. 18S (June 20 Supplement), 2007: 7714. Author(s): J. C. ZHU, T. D. Yan, K. Ng, D. Glenn, D. L. Morris.
  3. American Urological Association Policy Statement. Ablation of Renal Masses. 10/06.
  4. Bhatia S, Pereira K, Mohah P et al. Radiofrequency ablation in primary non-small cell lung cancer: What a radiologist needs to know. Indian Journal of Radiology Imaging 2016; 26(1): 81–91.
  5. Bilal H, Mahmood S, Rajashanker B et al. Is radiofrequency ablation more effective than stereotactic ablative radiotherapy in patients with early stage medically inoperable non-small cell lung cancer? Interactive and Cardiovascular Thoracic Surgery 2012;15(2):25.
  6. Blue Cross Blue Shield Association Medical Policy Reference 7.01.95, Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors, 09/17.
  7. Burak WE Jr, et al. Radiofrequency ablation of invasive breast carcinoma followed by delayed surgical excision. Cancer 10/01/03; 98(7): 1369-76.
  8. Chua TC, Sarkar A, Saxena A, Glenn D, Zhao J, Morris DL. Long-term outcome of image-guided percutaneous radiofrequency ablation of lung metastases: an open-labeled prospective trial of 148 patients. Ann Oncol. 2010 Oct;21(10):2017-22. Epub 2010 Mar 24.
  9. Goetz MP, et al. Percutaneous image-guided radiofrequency ablation of painful metastases involving bone: a multicenter study. J Clin Oncol 2004; 22(2): 300-306.
  10. Hayashi AH, et al. Treatment of invasive breast carcinoma with ultrasound-guided radiofrequency ablation. AM J Surg 05/03; 185(5): 429-35.
  11. Hess A, Palussière J, Goyers JF, Guth A, Aupérin A, de Baère T. Pulmonary radiofrequency ablation in patients with a single lung: feasibility, efficacy, and tolerance. Radiology. 2011 Feb;258(2):635-42.
  12. Huh JY, Baek JH, Choi H, Kim JK, Lee JH.Symptomatic benign thyroid nodules: efficacy of additional radiofrequency ablation treatment session--prospective randomized study. Radiology. 2012 Jun;263(3):909-16.
  13. Kim JH, Yoo WS1, Park YJ et al. Efficacy and Safety of Radiofrequency Ablation for Treatment of Locally Recurrent Thyroid Cancers Smaller than 2 cm. Radiology 2015;276(3): 909-918.
  14. King J, Glenn D., Clark W et al. Percutaneous radiofrequency ablation of pulmonary metastases in patients with colorectal cancer. Br J Surg 2004; 91:217-23.
  15. Lee JM, et al. Percutaneous radiofrequency ablation for inoperable non-small cell lung cancer and metastases: Preliminary report. Radiology 2004; 230: 125-34.
  16. Matlaga BR, et al. Radiofrequency ablation of renal tumors. Curr Urol Rep 02/04; 5(1): 39-44.
  17. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology: Colon Cancer. Version 2.2017-March 13, 2017.
  18. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology: Kidney Cancer. Version 2.2018-September 7, 2017.
  19. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology: Non-small cell lung cancer. Version 6.2017-May 12, 2017.
  20. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology: Thyroid Carcinoma. Version 2.2017-May 17, 2017.
  21. National Guideline Clearinghouse. Treatment of non-small cell lung cancer stage I and stage II: ACCP evidence-based clinical practice guidelines (2nd Edition) – Summary completed by ECRI 08/22/03; verified 12/21/07.
  22. National Guideline Clearinghouse. Guideline Summary NGC-7946. ACR Appropriateness Criteria® nonsurgical treatment for non-small-cell lung cancer: good performance status/definitive intent (2010).
  23. National Guideline Clearinghouse. Guideline Summary NCG-7797. ACR Appropriateness Criteria® follow-up of renal cell carcinoma (2009).
  24. National Institute for Clinical Excellence. Percutaneous radiofrequency ablation for primary and secondary lung cancers – guidance. 07/06.
  25. National Institute for Clinical Excellence. Percutaneous radiofrequency ablation of renal cancer – guidance. 09/04.
  26. National Institute for Clinical Excellence (NICE). Computed tomography-guided thermocoagulation of osteoid osteoma [IPG53]. 2004, March.
  27. National Institute for Clinical Excellence (NICE). Percutaneous radiofrequency ablation of renal cancer [IPG353]. 2010, July.
  28. National Institute for Health and Clinical Excellence (NICE). Percutaneous radiofrequency ablation for primary and secondary lung cancers [IPG372] 2010, December.
  29. National Institute for Health and Care Excellence (NICE). Ultrasound-guided percutaneous radiofrequency ablation for benign thyroid nodules Interventional procedures guidance [IPG562]. 2016 June.
  30. Pautler, Stephen E MC, et al. Retroperitoneoscopic-guided radiofrequency ablation of renal tumors. Urologic Oncology Branch, National Cancer Institute and the Diagnostic Radiology Department, Warren G. Magnuson Clinical Center, NIH, Bethesda, Maryland. The Canadian Journal of Urology; 8(4); 08/01.
  31. Ratko TA, Vats V, Brock J, et al. Local Nonsurgical Therapies for Stage I and Symptomatic Obstructive Non-Small-Cell Lung Cancer (Comparative Effectiveness Review No. 112). Rockville (MD): Agency for Healthcare Research and Quality; 2013.
  32. Schaefer O, et al. CT-guided radiofrequency heat ablation of malignant lung tumors. Med Sci Monit 11/03; 9(11): MT127-31.
  33. Shah DR, Green S, Elliot A, McGahan JP, Khatri VP.Current oncologic applications of radiofrequency ablation therapies. World J Gastrointest Oncol. 2013 Apr 15;5(4):71-80.
  34. Singletary ES. Feasibility of radiofrequency ablation for primary breast cancer. Breast Cancer 2003; 10(1): 4-9.
  35. Singletary SE. Radiofrequency ablation of breast cancer. Am Surg 01/03; 69(1): 37-40.
  36. von Meyenfeldt EM, Prevoo W, Peyrot D, Lai A Fat N, Burgers SJ, Wouters MW, Klomp HM. Local progression after radiofrequency ablation for pulmonary metastases. Cancer. 2011 Aug 15;117(16):3781-7. doi: 10.1002/cncr.25958. Epub 2011 Feb 11.
  37. U.S. Food and Drug Administration (FDA) 510k Cool-tip™ RF Ablation System #K052796, Feb 3, 2006.
  38. Yin G, Chen M, Yang S et al. Treatment of uterine myomas by radiofrequency thermal ablation: a 10-year retrospective cohort study. Reproductive Sciences 2015 ;22(5):609-614.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 10/31/17.

GUIDELINE UPDATE INFORMATION:

03/15/04

New Medical Coverage Guideline.

03/15/05

Scheduled review with revisions consisting of adding coverage criteria regarding palliation of osteolytic bone lesions and osteomas.

01/01/06

Annual HCPCS coding update (added 50592).

03/15/06

Scheduled review; no change in coverage statement.

01/01/07

Annual HCPCS coding update (added 32998).

04/15/07

Scheduled review; added inoperable renal masses as a covered indication; added CPT code 50542.

05/15/07

Reformatted guideline.

04/15/08

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

04/15/09

Scheduled review; description section revised; no change in position statement; references updated.

01/01/10

Annual HCPCS coding update: simple revision of descriptor for code 32998.

05/15/11

Scheduled review; position statement unchanged; references updated; formatting changes.

09/15/11

Revision; formatting changes.

11/15/12

Annual review; position statement and references updated; formatting changes.

11/15/13

Annual review; position statement updated to include reference to thyroid tumors; Program Exceptions section updated; references updated; other formatting changes.

11/15/14

Annual review; position statement unchanged; references updated.

01/01/15

Annual coding update: revised 20982.

11/15/17

Review; updated description and references. Reformatted position statements. Added position statement and criteria for localized renal cell carcinoma. Revised experimental/investigational position statement (added prostate cancer).

01/01/18

Annual HCPCS code update. Revised 32998 code descriptor.

Date Printed: May 27, 2018: 07:34 PM