Anthem Blue Cross Connecticut CG-MED-81 Ultrasound Ablation for Oncologic Indications Form

This document addresses ultrasound ablative therapy for the treatment of oncologic conditions. There are currently two ultrasound ablative techniques. High intensity focused ultrasound (HIFU) or magnetic resonance guided focused ultrasound (MRgFUS) involves the use of a focused high-intensity convergent ultrasound beam to destroy targeted tissue in a small, focused area via sonication. HIFU has been proposed as a treatment for multiple oncologic conditions. Transurethral ultrasound ablation (TULSA), which delivers directional thermal ultrasound via a catheter inserted into the urethra, is specific to prostate cancer.

Note:

• See the following related document for HIFU treatment non-oncologic indications:
  • MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
• For information regarding other palliative treatments of metastatic bone lesions, please see the following:
  • CG-SURG-61 Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the Liver

Clinical Indications

Medically Necessary:

The use of high intensity focused ultrasound (HIFU) is considered medically necessary for pain palliation in individuals with localized metastatic bone pain when all the following criteria are met:

1. Age 18 years or older; and
2. Metastatic lesions located 1 centimeter (cm) or greater from skin and major nerve bundles; and
3. Individual does not present an increased risk of fracture from the procedure (for example, a score of 7 or less on Mirel’s fracture risk score); and
4. Individual does not require surgical stabilization or have clinically significant comorbidities; and
5. Individual is not a candidate for other therapies as evidenced by pain refractory to previous radiation therapy.

Not Medically Necessary:

High intensity focused ultrasound (HIFU) is considered not medically necessary when the above criteria are not met and for all other indications, including but not limited to, the treatment of prostate cancer.

TULSA is considered not medically necessary for any indication, including but not limited to prostate cancer.