Anthem Blue Cross Connecticut RAD.00059 Catheter-based Embolization Procedures for Malignant Lesions Outside the Liver Form

This document addresses the use of transcatheter arterial chemoembolization (TACE) and transcatheter arterial embolization (TAE) for malignant lesions outside the liver. These catheter-based embolization procedures are proposed as adjunct therapeutic interventions prior to operative resection or for palliation of symptoms.

Note:

• This document does not address malignant lesions of the central nervous system (intracranial and spinal).
• This document does not address TACE or TAE as therapeutic interventions for actively bleeding malignant or non-malignant lesions, or for services addressed in any of the documents noted below.

Note: For additional information please refer to the following related documents:

• CG-SURG-28 Transcatheter Uterine Artery Embolization
• CG-SURG-61 Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the Liver
• CG-SURG-78 Locoregional Techniques for Treating Primary and Metastatic Liver Malignancies

Investigational and Not Medically Necessary:

Transcatheter arterial chemoembolization and transcatheter arterial embolization are considered investigational and not medically necessary for malignant lesions outside the liver.