Anthem Blue Cross Connecticut SURG.00126 Irreversible Electroporation Form

This document addresses use of irreversible electroporation (IRE, also known as pulsed field ablation [PFA]). This document exclusively addresses all uses of irreversible electroporation (IRE), as a specific form of tissue ablation.

Note: For information related to other ablative techniques for cancer treatment, please see:

• CG-MED-64 Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins
• 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

Position Statement

Investigational and Not Medically Necessary:

Irreversible electroporation is considered investigational and not medically necessary for all indications, including, but not limited to, ablation of soft tissue or of solid organs, such as the liver and pancreas.