Anthem Blue Cross Connecticut CG-SURG-61 Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the Liver Form

This document focuses on the use of cryosurgical (also known as cryosurgery or cryoablation), radiofrequency, microwave or laser ablation as a treatment of:

• Primary or secondary malignancies outside the liver; and
• Benign tumors outside the liver.

Note: This document does not address the treatment of epithelial or endothelial lesions, including basal and squamous cell carcinoma, Barrett’s esophagus, polyps of the esophagus or condylomata.

Note: This document does not address treatment for benign prostatic hypertrophy (BPH). For criteria related to BPH treatment, refer to applicable guidelines used by the plan.

Note: For additional information, see the following:

• CG-MED-81 Ultrasound Ablation for Oncologic Indications
• CG-SURG-78 Locoregional Techniques for Treating Primary and Metastatic Liver Malignancies
• CG-SURG-101 Ablative Techniques as a Treatment for Barrett’s Esophagus
• SURG.00159 Focal Laser Ablation for the Treatment of Prostate Cancer

Clinical Indications

Medically Necessary:

Prostate Cancer

Whole-gland cryosurgical ablation of the prostate is considered medically necessary as a treatment of prostate cancer.

Non-small cell lung cancer (NSCLC)

Thermal ablation (radiofrequency ablation, cryoablation or microwave ablation) of NSCLC is considered medically necessary when all of the following criteria are met:

1. Surgical or radiation treatment with curative intent is considered appropriate based on stage of disease, however medical co-morbidity renders the individual unfit for those interventions; and
2. No tumor has a maximum diameter of greater than 3.0 cm; and
3. Tumors are located at least 1 cm from the trachea, main bronchi, esophagus, aorta, aortic arch branches, pulmonary artery and the heart.

Tumor(s) that have metastasized to the lung

Thermal ablation (radiofrequency ablation, cryoablation or microwave ablation) of malignant tumor(s) that have metastasized to the lung is considered medically necessary when all of the following criteria are met:

1. Surgical or radiation treatment is considered appropriate based on stage of disease, however medical co-morbidity renders the individual unfit for those interventions; and
2. There is no current active extra-pulmonary metastatic disease; and
3. There are no more than 3 tumors per lung; and
4. No tumor has a maximum diameter greater than 3.0 cm; and
5. Tumors are located at least 1 cm from the trachea, main bronchi, esophagus, aorta, aortic arch branches, pulmonary artery and the heart.

Osteoid osteomas

Radiofrequency ablation of osteoid osteomas is considered medically necessary.

Bone metastases

Radiofrequency ablation of painful bony metastases is considered medically necessary in individuals who have failed or who are considered poor candidates for standard treatments such as opioids or radiation therapy.

Renal malignancy

Radiofrequency ablation or cryoablation for clinically localized, suspected renal malignancy is considered medically necessary for individuals with peripheral lesions that are less than or equal to 4 cm in diameter.

Not Medically Necessary:

Focal cryosurgical ablation of prostate tumors is considered not medically necessary.

Laser ablation, or laser interstitial thermal therapy is considered not medically necessary as a therapy to treat solid tumors outside the liver.

Thermal ablation (radiofrequency ablation, cryoablation, or microwave ablation) of tumors outside the liver is considered not medically necessary when the above criteria are not met and for all other indications.