Cryosurgical Ablation of Primary or Metastatic Liver Tumors Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 02|17|2015 POLICY LAST REVIEWED: 09|17|2025 OVERVIEW Cryosurgical ablation involves the freezing of target tissues, most often by inserting into the tumor a probe through which coolant is circulated. Cryosurgical ablation can be performed as an open surgical technique or percutaneously or laparoscopically, typically with ultrasound guidance. MEDICAL CRITERIA Not applicable PRIOR AUTHORIZATION Not applicable POLICY STATEMENT Medicare Advantage Plans Cryosurgical ablation of either primary or metastatic tumors in the liver is not covered as the evidence is insufficient to determine the effects of the technology on health outcomes.
Commercial Products Cryosurgical ablation of either primary or metastatic tumors in the liver is not medically necessary as the evidence is insufficient to determine the effects of the technology on health outcomes.
COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate Evidence of Coverage, Subscriber Agreement for applicable not medically necessary benefits/not covered coverage. BACKGROUND Cryosurgical ablation (CSA) involves the freezing of target tissues, often by inserting a probe through which coolant is circulated into the tumor. CSA can be performed as an open surgical technique or percutaneously or laparoscopically, typically with ultrasound guidance. For individuals who have unresectable primary hepatocellular carcinoma amenable to locoregional therapy who receive CSA, the evidence includes 1 randomized controlled trial (RCT), several nonrandomized comparative studies, and multiple noncomparative studies. Relevant outcomes are overall survival, disease-specific survival, and treatment-related mortality and morbidity. The available RCT comparing cryoablation with radiofrequency ablation demonstrated lower rates of local tumor progression with cryoablation, but no differences in survival outcomes between groups. Although this trial provided suggestive evidence that cryoablation is comparable with radiofrequency ablation, trial limitations would suggest findings need to be replicated. Additional comparative evidence is needed to permit conclusions about the effectiveness of cryoablation compared with other locoregional therapies. The evidence is insufficient to determine the effects of the technology on health outcomes. For individuals who have unresectable liver metastases from neuroendocrine tumors amenable to locoregional therapy who receive CSA, the evidence includes a Cochrane review and case series. Relevant outcomes are overall survival, disease-specific survival, symptoms, and treatment-related mortality and morbidity. The available evidence base is very limited. The evidence is insufficient to determine the effects of the technology on health outcomes.
For individuals who have unresectable liver metastases from colorectal cancer amenable to locoregional therapy who have CSA, the evidence includes 1 RCT, a number of nonrandomized comparative and Medical Coverage Policy | Cryosurgical Ablation of Primary or Metastatic Liver Tumors

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

noncomparative studies, and systematic reviews of these studies. Relevant outcomes are overall survival, disease-specific survival, and treatment-related mortality and morbidity. The available RCT comparing surgical resection with cryoablation was judged at high risk of bias. Some nonrandomized comparative studies have reported improved survival outcomes for patients managed with cryotherapy compared with those managed with resection alone; however, these studies were subject to bias in the selection of patients for treatments. Additional controlled studies are needed to permit conclusions about the effectiveness of cryoablation compared with other locoregional therapies. The evidence is insufficient to determine the effects of the technology on health outcomes.

CODING Medicare Advantage Plans and Commercial Products
The following CPT code(s) are not covered for Medicare Advantage Plans and not medically necessary Commercial Products: 47371 Laparoscopy, surgical, ablation of 1 or more liver tumor(s); cryosurgical 47381 Ablation, open, 1 or more liver tumor(s); cryosurgical
47383 Ablation, 1 or more liver tumor(s), percutaneous, cryoablation

RELATED POLICIES None

PUBLISHED Provider Update, November 2025 Provider Update, January 2025 Provider Update, January 2024 Provider Update, January 2023 Provider Update, December 2021

REFERENCES:

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500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

10. Ko SE, Lee MW, Rhim H, et al. Comparison of procedure-related complications between percutaneous cryoablation and radiofrequency ablation for treating periductal hepatocellular carcinoma. Int J Hyperthermia. Nov 17 2020; 37(1): 1354-1361. PMID 33297809
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500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 4 (401) 274-4848 WWW.BCBSRI.COM

30. Niu R, Yan TD, Zhu JC, et al. Recurrence and survival outcomes after hepatic resection with or without cryotherapy for liver metastases from colorectal carcinoma. Ann Surg Oncol. Jul 2007; 14(7): 2078-87. PMID 17473951
31. Joosten J, Jager G, Oyen W, et al. Cryosurgery and radiofrequency ablation for unresectable colorectal liver metastases. Eur J Surg Oncol. Dec 2005; 31(10): 1152-9. PMID 16126363
32. Ng KM, Chua TC, Saxena A, et al. Two decades of experience with hepatic cryotherapy for advanced colorectal metastases. Ann Surg Oncol. Apr 2012; 19(4): 1276-83. PMID 21913018
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36. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology: Hepatocellular Carcinoma. Version 1.2025. https://www.nccn.org/professionals/physician_gls/PDF/hcc.pdf. Accessed July 29, 2025.
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38. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology: Neuroendocrine and Adrenal Tumors. Version 2.2025. https://www.nccn.org/professionals/physician_gls/PDF/neuroendocrine.pdf. Accessed July 27,

40. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology: Colon Cancer. Version 4.2025. https://www.nccn.org/professionals/physician_gls/PDF/colon.pdf. Accessed July 28, 2025. .

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    This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.

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