Description

Radiofrequency (RF) tumor ablation is a procedure in which a needle electrode is inserted via image guidance into a tumor (lesion) and electrical energy generates heat to destroy cancer cells. The current moves from the tip of the electrode into the surrounding tissue. The movement of ions results in frictional heating of the tissue and as the temperature becomes elevated beyond 60 degrees Celsius, cells around the electrode undergo necrosis (begin to die).

RF tumor ablation can be performed laparoscopically, percutaneously or intraoperatively; however, it is typically used for individuals whose tumors are inoperable or for those who cannot undergo a surgical procedure due to age, presence of comorbidities or overall poor general health.

Radiofrequency Tumor Ablation

Effective Date: 09/28/2023

Revision Date: 09/28/2023

Review Date: 09/28/2023

Policy Number: HUM-0339-016

Page: 2 of 14

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 ablation, please refer to Microwave Thermotherapy Medical Coverage Policy.

Coverage Determination

Please refer to the member’s applicable pharmacy benefit to determine benefit availability and the terms and conditions of coverage for medication for the treatment of cancer pain.

Humana members may be eligible under the Plan for RF tumor ablation when the following criteria are met:

• Differentiated thyroid cancer for the following indications:
  1. Distant metastatic disease not amenable to radioactive iodine (RAI); OR
  2. Persistent/recurrent, nonmetastatic disease; OR
• Malignant painful bone tumors in an individual who has failed or cannot tolerate conventional treatments, such as medication or radiation therapy; OR
• Metastatic and nonmetastatic (primary) lung cancer in an individual who is not a candidate for surgical intervention; OR
• Nonmetastatic renal cancer in an individual who is not a candidate for surgical intervention; OR
• Osteoid osteoma in an individual who remains symptomatic despite treatment with nonsteroidal anti-inflammatory drugs (NSAIDs); OR
• Soft tissue sarcoma for the following indications:
  1. Gastrointestinal stromal tumors with limited progressive disease (defined as appearance of no new lesion or increase in tumor size); OR
  2. Synchronous stage IV soft tissue sarcoma with either of the following:
     • Palliation of symptomatic disseminated metastases;
     • Radiofrequency Tumor Ablation Effective Date: 09/28/2023

Policy Number: HUM-0339-016 Page: 3 of 14

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.

• Single organ and limited tumor bulk that are amenable to local therapies; OR
• Unresectable, metastatic hepatic tumors whose primary site is from colorectal cancer or neuroendocrine cancer; 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 RF tumor ablation for any indications other than those listed above including, but may not be limited to:

• Breast tumors; OR
• Metastatic hepatic tumors whose primary site is any other than colon, neuroendocrine or rectum; OR
• Prostate cancer; OR
• Spinal tumors or spinal metastases

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.

Additional information about cancer or noncancerous tumors of the bone may be found from the following websites:

Background

• American Academy of Orthopedic Surgeons
• American Cancer Society
• National Comprehensive Cancer Network
• National Library of Medicine

Radiofrequency Tumor Ablation Effective Date: 09/28/2023 Revision Date: 09/28/2023 Review Date: 09/28/2023 Policy Number: HUM-0339-016 Page: 4 of 14

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.

Medical Alternatives

Alternatives to RF tumor ablation include, but may not be limited to, the following:

• Cryoablation (please refer to Cryoablation Medical Coverage Policy)
• Microwave ablation (please refer to Microwave Thermotherapy Medical Coverage Policy)

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

Humana may offer a disease management program for this condition. The member may call the number on his/her identification card to ask about our programs to help manage his/her care.

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.