HumanaCommercial Clinical Policy

Microwave Thermotherapy Form


Notes: Coverage for microwave thermotherapy is limited to very specific indications, and it is not covered for other uses deemed experimental or investigational.

Indications

(217325) Is the microwave thermotherapy for treatment of unresectable, metastatic hepatic tumors whose primary site is colorectal cancer or neuroendocrine tumors? 
(217326) Is the microwave thermotherapy for treatment of unresectable primary malignant hepatic tumors less than or equal to 3 cm without nodal or extrahepatic metastases? 

Contraindications

(217327) Is the microwave thermotherapy for treatment of any cancer type other than unresectable, metastatic hepatic tumors with a primary site of colorectal cancer or neuroendocrine tumors, or unresectable primary malignant hepatic tumors less than or equal to 3 cm without nodal or extrahepatic metastases? 
(217328) Does the use of microwave thermotherapy fall under an experimental/investigational category not widely used and generally accepted as reported in nationally recognized peer-reviewed medical literature published in the English language? 
Effective Date

09/28/2023

Last Reviewed

NA

Original Document

  Reference



Description

Microwave thermotherapy, also known as microwave ablation or microwave therapy, is similar to radiofrequency ablation (RFA) in that it is a treatment used for cancer that involves heating of tissues to destroy cancer cells. Electromagnetic energy is utilized to heat the target tissue, which causes damage to the cell’s membrane resulting in cell death or increasing the sensitivity of the cells to radiation therapy. The microwave energy radiates into the tissue through an antenna that allows direct heating of a volume of tissue around the antenna.

Microwave thermotherapy systems include a generator and electrodes that are placed into the targeted area via an access needle. Microwaves are then distributed to the site. Liquids may be circulated through the needle shaft to permit continuous cooling to the insertion site; thereby avoiding burning of the skin.

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Microwave Thermotherapy Effective Date: 09/28/2023
Revision Date: 09/28/2023
Review Date: 09/28/2023
Policy Number: HUM-0568-006
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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

For information regarding microwave thermotherapy for benign prostatic hyperplasia (BPH), please refer to Benign Prostatic Hyperplasia Treatments Medical Coverage Policy.

For information regarding radiofrequency ablation, please refer to Radiofrequency Tumor Ablation Medical Coverage Policy.

Coverage Determination

Humana members may be eligible under the Plan for microwave thermotherapy for the following indications:

  • Unresectable, metastatic hepatic tumors whose primary site is from colorectal cancer or neuroendocrine tumors; OR
  • Unresectable primary malignant hepatic tumors less than or equal to 3 cm without nodal or extrahepatic metastases

Coverage Limitations

Humana members may NOT be eligible under the Plan for microwave thermotherapy for any indications other than those listed above including, but may not be limited to:

  • Bone cancer; OR
  • Breast cancer; OR
  • Cholangiocarcinoma; OR
  • Lung cancer; OR
  • Pancreatic cancer; OR
  • Prostate cancer; OR
  • Renal cell cancer

This is considered experimental/investigational as it is not identified as widely used and generally accepted for any other proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Background

Additional information about cancer may be found from the following websites:

  • American Cancer Society
  • National Comprehensive Cancer Network
  • National Library of Medicine

Medical Alternatives

Alternatives to microwave thermotherapy include, but may not be limited to:

  • Cryoablation (please refer to Cryoablation Medical Coverage Policy).
  • Radiofrequency ablation (please refer to Radiofrequency Tumor Ablation Medical Coverage Policy).

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.