Anthem Blue Cross Connecticut Commercial Clinical Policy

Anthem Blue Cross Connecticut SURG.00149 Percutaneous Ultrasonic Ablation of Soft Tissue Form

Effective Date

04/12/2023

Last Reviewed

02/16/2023

Original Document

  Reference



This document addresses the use of percutaneous ultrasonic ablation (emulsification) of soft tissue for the treatment of any condition.

Note: Please see the following related documents for additional information:

  • SURG.00045 Extracorporeal Shock Wave Therapy
  • SURG.00088 Coblation® Therapies for Musculoskeletal Conditions
  • SURG.00100 Cryoablation for Plantar Fasciitis and Plantar Fibroma

Note: This document does not address the use of high intensity focused ultrasound (HIFU) ablation for any indication. For information regarding HIFU ablation, please see the following documents:

  • CG-MED-81 Ultrasound Ablation for Oncologic Indications
  • MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications

Position Statement

Investigational and Not Medically Necessary:

Percutaneous ultrasonic ablation of soft tissue is considered investigational and not medically necessary for the treatment of any condition, including, but not limited to any of the following musculoskeletal conditions:

  1. Achilles tendinosis; or
  2. Lateral or medial elbow tendinosis; or
  3. Patellar tendinosis; or
  4. Recalcitrant plantar fasciitis; or
  5. Rotator cuff or shoulder tendinosis.