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Medical Policy Cryosurgical Ablation of Primary or Metastatic Liver Tumors Table of Contents
• Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 633 BCBSA Reference Number: 7.01.75 (For Plan internal use only) NCD/LCD: NA Related Policies
• Isolated Limb Perfusion, #124 • Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors, #259 • Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate or Dermatologic Tumors, #260 • Radiofrequency Ablation of Primary or Metastatic Liver Tumors, #286 • Microwave Tumor Ablation, #912 • Transcatheter Arterial Chemoembolization to Treat Primary or Metastatic Liver Malignancies, #634 • Radioembolization for Primary and Metastatic Tumors of the Liver, #292 Policy
Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity
Medicare HMO BlueSM and Medicare PPO BlueSM Members

Cryosurgical ablation of either primary or metastatic tumors in the liver is INVESTIGATIONAL. Prior Authorization Information Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) This is not a covered service. Commercial PPO and Indemnity This is not a covered service. Medicare HMO BlueSM This is not a covered service. Medicare PPO BlueSM This is not a covered service.

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CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable. The following codes are included below for informational purposes only; this is not an all-inclusive list. The following CPT codes are considered investigational for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue:

CPT Codes CPT codes: Code Description 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

Description Liver Metastases Hepatic tumors can be due to primary liver cancer or metastases to the liver from nonhepatic primary tumors. Primary liver cancer can arise from hepatocellular tissue (hepatocellular carcinoma [HCC]) or intrahepatic biliary ducts (cholangiocarcinoma). Multiple tumors metastasize to the liver, but there is particular interest in the treatment of hepatic metastases from colorectal cancer (CRC) given the propensity of CRC to metastasize to the liver and its high prevalence. Liver metastases from neuroendocrine tumors present a unique clinical situation. Neuroendocrine cells produce and secrete a variety of regulatory hormones (or neuropeptides), which include neurotransmitters and growth factors. Overproduction of the specific neuropeptides by cancerous cells causes various symptoms, depending on the hormone produced. In the U.S, the incidence rates of liver cancer are estimated to continually increase through 2030. 1, Some racial groups are more affected by liver cancer than others due to differences in the prevalence of risk factors and disparities in access to quality care; the mortality rate for African Americans with HCC is higher than other racial groups in the U.S. Treatment Surgical resection with tumor-free margins and liver transplantation are the primary treatments available that have curative potential. Many hepatic tumors are unresectable at diagnosis, due either to their anatomic location, size, the number of lesions, or underlying liver reserve. Local therapy for hepatic metastasis is indicated only when there is no extrahepatic disease, which rarely occurs for patients with primary cancers other than CRC or certain neuroendocrine malignancies. For liver metastases from CRC, postsurgical adjuvant chemotherapy has been reported to decrease recurrence rates and prolong the time to recurrence. Combined systemic and hepatic arterial chemotherapy may increase disease-free intervals for patients with hepatic metastases from CRC but apparently is not beneficial for those with unresectable hepatocellular carcinoma. Various locoregional therapies for unresectable liver tumors have been evaluated: cryosurgical ablation (cryosurgery); radiofrequency ablation; laser ablation; transhepatic arterial embolization, chemoembolization, or radioembolization with yttrium-90 microspheres; microwave coagulation; and percutaneous ethanol injection. Cryosurgical ablation occurs in tissue that has been frozen by at least 3 mechanisms: (1) formation of ice crystals within cells, thereby disrupting membranes and interrupting cellular metabolism among other processes; (2) coagulation of blood, thereby interrupting blood flow to the tissue, in turn causing ischemia and apoptosis; and (3) induction of apoptosis.

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Some have reported on experience with cryosurgical and other ablative methods used in combination with subtotal resection and/or procedures such as transarterial chemoembolization. Procedure-Related Complications Cryosurgery is not a benign procedure. Treatment-related deaths occur in approximately 2% of study populations and are most often caused by cryoshock, liver failure, hemorrhage, pneumonia/sepsis, and acute myocardial infarction. Clinically significant nonfatal complication rates in the reviewed studies ranged from 0% to 83% and were generally due to the same causes as treatment-related deaths. The likelihood of complications arising from cryosurgery might be predicted, in part, by the extent of the procedure,2, but much of the treatment-related morbidity and mortality reflect the generally poor health status of patients with advanced hepatic disease. Summary Description 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. Summary of Evidence For individuals who have unresectable primary hepatocellular carcinoma (HCC) amenable to locoregional therapy who receive cryosurgical ablation (CSA), the evidence includes two meta-analyses, one randomized controlled trial (RCT), several nonrandomized comparative studies, and multiple noncomparative studies. Relevant outcomes are overall survival (OS), disease-specific survival, and treatment-related mortality and morbidity. The available RCT comparing cryoablation with radiofrequency ablation (RFA) 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 RFA, trial limitations would suggest findings need to be replicated. Nonrandomized comparative studies have failed to find consistent benefit with cryoablation in outcomes related to tumor recurrence and survival. Evidence from 2 meta-analyses which included RCTs suggests equivalent OS and progression-free survival to RFA and superiority for combined transarterial chemoembolization (TACE) plus CSA over TACE alone for OS and tumor progression. Additional randomized comparative evidence is needed to permit conclusions about the effectiveness of cryoablation compared with other locoregional therapies. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

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 OS, disease-specific survival, symptoms, and treatment-related mortality and morbidity. The available evidence base is very limited. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have unresectable liver metastases from colorectal cancer amenable to locoregional therapy who have CSA, the evidence includes an RCT, several nonrandomized comparative and noncomparative studies, and systematic reviews of these studies. Relevant outcomes are OS, disease- specific survival, and treatment-related mortality and morbidity. The available RCT comparing surgical resection with cryoablation was judged as 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 that the technology results in an improvement in the net health outcome. Policy History Date Action

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11/2025 Annual policy review. Policy updated with literature review through July 29, 2025; reference added; guidelines updated. Policy statement unchanged. 11/2024 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 11/2023 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 10/2022 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 10/2021 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 11/2020 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 10/2019 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 9/2018 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 7/2017 Annual policy review. New references added. 6/2016 Annual policy review. Missing word “be” added to first sentence in Background section. 1/2016 Annual policy review. New references added. 2/2015 Annual policy review. New references added. 1/2015 Clarified coding information. 3/2014 Annual policy review. New references added. 11/2011- 4/2012 Medical policy ICD 10 remediation: Formatting, editing and coding updates. No changes to policy statements.
12/2011 Annual policy review. No changes to policy statements. 10/2011 Reviewed - Medical Policy Group - Gastroenterology, Nutrition and Organ Transplantation. No changes to policy statements. 7/2011 Reviewed - Medical Policy Group - Hematology and Oncology. No changes to policy statements. 11/2010 Reviewed - Medical Policy Group - Gastroenterology, Nutrition and Organ Transplantation. No changes to policy statements. 9/2010 Reviewed - Medical Policy Group - Hematology and Oncology. No changes to policy statements. 6/2010 Annual policy review. No changes to policy statements. 9/2009 Reviewed - Medical Policy Group - Hematology and Oncology. No changes to policy statements. 9/2009 Annual policy review. No changes to policy statements. 11/2008 Reviewed - Medical Policy Group - Gastroenterology, Nutrition and Organ Transplantation. No changes to policy statements. 10/2008 Annual policy review. No changes to policy statements. 9/2008 Annual policy review. Changes to policy statements. 1/2008 Annual policy review. Changes to policy statements. Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines

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References

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3. Kim HI, An J, Han S, et al. Loco-regional therapies competing with radiofrequency ablation in potential indications for hepatocellular carcinoma: a network meta-analysis. Clin Mol Hepatol. Oct 2023; 29(4): 1013-1028. PMID 37403319
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20. Jaeck D, Oussoultzoglou E, Bachellier P, et al. Hepatic metastases of gastroenteropancreatic neuroendocrine tumors: safe hepatic surgery. World J Surg. Jun 2001; 25(6): 689-92. PMID 11376398
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