Humana Commercial Clinical Policy

Humana Cryoablation Form


Effective Date

12/14/2023

Last Reviewed

NA

Original Document

  Reference



Description

Cryoablation (also known as cryotherapy or cryosurgery) involves the internal or external use of liquid nitrogen or argon gas at extreme cold temperatures to destroy diseased tissue. For external uses, the liquid nitrogen is applied directly with a cotton swab or spray device. For internal purposes, either argon gas or liquid nitrogen is circulated through a cryoprobe that has been situated next to diseased tissue via image guidance, such as ultrasound, magnetic resonance imaging (MRI) or computed tomography (CT), which reportedly ensures less damage to nearby healthy tissue. Ice crystals form around the probe, which freezes the cells. Once the cells thaw, the body absorbs them.

Cryoablation may be used to treat several types of cancer including, but may not be limited to, cervical, kidney, liver and prostate. Cryoablation has also been used in precancerous conditions to avoid the development of cancer (eg, cervical intraepithelial neoplasia [CIN]).

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Cryoablation Effective Date: 12/14/2023

Revision Date: 12/14/2023

Review Date: 12/14/2023

Policy Number: HUM-0428-027

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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.

Cryoablation may be utilized for the treatment of cutaneous (superficial) basal cell carcinoma (BCC) and squamous cell carcinoma in situ (Bowen disease) in which surgery is contraindicated. Choice of treatment depends on factors such as anatomic location, risk factors for tumor recurrence, age and health status of the individual.

Cryoablation may purportedly be utilized for the treatment of cutaneous melanoma; however, data appears to be insufficient to support its use for this indication. (Refer to Coverage Limitations section)

Other areas being studied for the use of cryoablation include, but may not be limited to, Barrett’s esophagus, bone tumors, breast cancer, breast fibroadenomas, esophageal cancer, pulmonary tumors, non-small cell lung cancer (NSCLC) as well as thyroid cancer. (Refer to Coverage Limitations section)

Cryotherapy is proposed for the use of ocular conditions such as retinal detachment. This treatment is designed to create scar tissue, which will seal the tear or help the retina reattach to the underlying tissue to keep it in the correct position.

Cryotherapy is being investigated for the treatment of uveal melanoma, retinopathy (eg, diabetic retinopathy, retinopathy of prematurity) or conjunctival lesions. (Refer to Coverage Limitations section)

Cryoablation has also been utilized for noncancerous conditions such as atrial fibrillation, benign prostatic hyperplasia, benign skin lesions, chronic nerve pain, chronic spinal pain, plantar fasciitis, uterine fibroids as well as varicose veins.

For coverage determination/limitations information regarding cryoablation for conditions not addressed in this medical coverage policy, please refer to the following:

  • Actinic Keratoses - Actinic Keratoses Treatments
  • Atrial fibrillation - Cardiac Electrophysiological Studies and Cardiac Catheter Ablation
  • Benign prostatic hyperplasia | Benign Prostatic Hyperplasia Treatments

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Cryoablation Effective Date: 12/14/2023

Revision Date: 12/14/2023

Review Date: 12/14/2023

Policy Number: HUM-0428-027

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • Chronic nerve and spinal pain - Neuroablative Techniques for Chronic Pain
  • Chronic rhinitis - Balloon Dilation (Eustachian Tube and Sinus) and Functional Endoscopic Sinus Surgery
  • Plantar fasciitis - Plantar Fasciitis Treatments
  • Uterine fibroids - Uterine Fibroid Surgical Treatments
  • Varicose veins - Varicose Vein Treatments

Coverage Determination—Humana members may be eligible under the Plan for cryoablation for the following indications:

  • Cervical intraepithelial neoplasia (CIN) grade 1, 2 or 3; OR
  • Endometrial cryoablation for premenopausal women with menorrhagia (excessive bleeding) not related to uterine fibroids and whom childbearing is complete and are refractory to medical treatment; OR
  • Localized, cutaneous (superficial) BCC in which surgery or radiation therapy is contraindicated; OR
  • Localized, cutaneous (superficial) squamous cell carcinoma in situ (Bowen disease) in which surgery is contraindicated; OR
  • Malignant inoperable endobronchial obstruction in a symptomatic individual; OR
  • Prostate cancer as a primary therapy alternative to surgery or irradiation in individuals with localized disease (eg, TNM stage T1-T3) OR as salvage therapy for recurrent cancer following failure of radiation therapy; OR
  • Renal cell cancer in individuals who are not candidates for partial nephrectomy, radical nephrectomy or radiofrequency ablation (RFA); OR
  • Retinal detachment; OR
  • Retinopathy of prematurity; OR
  • Soft tissue sarcoma of the extremities or the trunk in symptomatic individuals with disseminated metastases; OR Unresectable malignant primary or metastatic liver tumors Note: The criteria for cryoablation of the prostate are not consistent with the Medicare National Coverage Policy and therefore may not be applicable to Medicare members. Refer to the CMS website for additional information.

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Policy Number: HUM-0428-027

Coverage Limitations

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

  • Barrett’s esophagus; OR
  • Bone tumors (primary or metastatic); OR
  • Breast cancer; OR
  • Breast fibroadenomas; OR
  • Conjunctival lesions; OR
  • Cutaneous melanoma; OR
  • Diabetic retinopathy; OR
  • Esophageal cancer; OR
  • Morton’s neuromas; OR
  • Pancreatic cancer; OR
  • Peripheral neuropathy; OR
  • Plantar fibromas; OR
  • Pulmonary tumors (eg, NSCLC); OR
  • Thyroid cancer; OR
  • Uveal melanoma These are considered experimental/investigational as they are not identified as widely used and generally accepted for any other proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

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Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Additional information about cancer, menorrhagia, retinopathy of prematurity or skin lesions may be found from the following websites:

Background

  • American Academy of Dermatology
  • American Academy of Pediatrics
  • American Cancer Society
  • American College of Obstetricians and Gynecologists
  • National Library of Medicine

Medical Alternatives

Alternatives to cryoablation include, but may not be limited to, the following:

  • Prescription drug therapy
  • Radiation
  • Surgery

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.

Cryoablation Effective Date: 12/14/2023

Revision Date: 12/14/2023

Review Date: 12/14/2023

Policy Number: HUM-0428-027

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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.

  • 17262 - Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 1.1 to 2.0 cm
  • 17263 - Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 2.1 to 3.0 cm
  • 17264 - Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 3.1 to 4.0 cm
  • 17266 - Destruction, malignant lesion (eg, cryosurgery, chemosurgery, surgical or legs; lesion diameter over 4.0 cm aser surgery, electrosurgery, curettement), trunk, arms
  • 17270 - Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less
  • 17271 - Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm
  • 17272 - Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgica hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm curettement), scalp, neck,
  • 17273 - Destruction, malignant lesion (eg, cryosurgery, chemosurgery, surgic hands, feet, genitalia; lesion diameter 2.1 to 3.0 cm aser surgery, electrosurgery, al curettement), scalp, neck,
  • 17274 - Destruction, malignant lesion (eg, cryosurgery, chemosurgery, surgic hands, feet, genitalia; lesion diameter 3.1 to 4.0 cm aser surgery, electrosurgery, al curettement), scalp, neck,
  • 17276 - Destruction, malignant lesion (eg, cryosurgery, chemosurgery, surgic hands, feet, genitalia; lesion diameter over 4.0 cm aser surgery, electrosurgery, al curettement), scalp, neck,
  • 17280 - Destruction, malignant lesion (eg, cryosurgery, chemosurgery, surgic eyelids, lips, membr aser surgery, electrosurgery, al curettement), face, ears, lesion diameter 0.5

Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less

Cryoablation Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
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  • 17281 - Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm
  • 17282 - Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cm
  • 17283 - Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 2.1 to 3.0 cm
  • 17284 - Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 3.1 to 4.0 cm
  • 17286 - Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter over 4.0 cm
  • 19105 - Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma Not Covered
  • 20983 - Ablation therapy for reduction or eradication of 1 or more bone tumors (eg, metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; cryoablation Not Covered
  • 31641 - Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with destruction of tumor or relief of stenosis by any method other than excision (eg, laser therapy, cryotherapy)
  • 32994 - Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by extension, including imaging Not Covered

Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, including imaging guidance when performed, unilateral; cryoablation

Cryoablation Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0428-027
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Repair of complex retinal detachment (eg, proliferative vitreoretinopathy, stage C-1 or greater, diabetic traction retinal detachment, retinopathy of prematurity, retinal tear of greater than 90 degrees), with vitrectomy and membrane peeling, including, when performed, air, gas, or silicone oil tamponade, cryotherapy, endolaser photocoagulation, drainage of subretinal fluid, scleral buckling, and/or removal of lens.

Cryoablation Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0428-027
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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.

  • 67229 - Treatment of retinopathy of prematurity, preterm infant (less than 37 weeks gestation at birth), from birth up to 1 year of age, photocoagulation or cryotherapy

CPT® Category Ill Code(s)

  • 0581T - Ablation, malignant breast tumor(s), percutaneous, cryotherapy, including imaging guidance when performed, unilateral - Not Covered

HCPCS Code(s)

  • C2618 - Probe/needle, cryoablation - Not Covered if used to report any procedure outlined in Coverage Limitations section

References

  • Agency for Healthcare Research and Quality (AHRQ). Comparative Effectiveness Review. Therapies for clinically localized prostate cancer. https://www.ahrq.gov. Published September 2020. Accessed October 20, 2022. Accessed December 5, 2023.
  • American Academy of Dermatology (AAD). Guidelines for the management of cutaneous squamous cell carcinoma. https://www.aad.org. Published March 2018.
  • American Academy of Dermatology (AAD). Guidelines of care for the management of basal cell carcinoma. https://www.aad.org. Published March 2018. Accessed November 16, 2023.
  • American Academy of Ophthalmology (AAO). Posterior vitreous detachment, retinal breaks, and lattice degeneration preferred practice pattern. https://www.aao.org. Published October 2019. Accessed November 16, 2023.
  • American Academy of Pediatrics (AAP). Policy Statement. Screening examination of premature infants for retinopathy of prematurity. https://www.aap.org. Published December 1, 2018. Accessed November 16, 2023.
  • American Association for the Study of Liver Diseases (AASLD). AASLD practice guidance on prevention, diagnosis and treatment of hepatocellular carcinoma. https://www.aasld.org. Published May 1, 2023. Accessed December 6, 2023.
  • American College of Chest Physicians (ACCP). Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. https://www.accp.com. Published May 2013. Updated August 4, 2020. Accessed November 16, 2023.
  • American College of Gastroenterology (ACG). Diagnostic and management of Barrett’s esophagus: an updated ACG guideline. https://gi.org. Published April 2022. Accessed November 16, 2023.
  • American College of Radiology (ACR). ACR Appropriateness Criteria. Locally advanced, high-risk prostate cancer. https://www.acr.org. Published 1996. Updated 2016. Accessed November 16, 2023.
  • American College of Radiology (ACR). ACR Appropriateness Criteria. Management of liver cancer. https://www.acr.org. Published 2022. Accessed December 6, 2023.
  • American Gastroenterological Association (AGA). AGA clinical practice update on endoscopic treatment of Barrett’s esophagus with dysplasia and/or early cancer: expert review. https://www.gastro.org. Published February 2020. Accessed November 16, 2023.
  • American Gastroenterological Association (AGA). American Gastroenterological Association medical position statement on the management of Barrett’s esophagus. https://www.gastro.org. Published March 2011. Accessed November 16, 2023.
  • American Radium Society (ARS). ACR Appropriateness Criteria. Locally advanced, high-risk prostate cancer. https://www.americanradiumsociety.org. Published 1996. Updated 2016. Accessed November 16, 2023.
  • American Radium Society (ARS). American Radium Society appropriate use criteria for the use of liver-directed therapies for management of non-surgical liver metastases: systemic review and guidelines. https://www.americanradiumsociety.org. Published July 2023. Accessed December 6, 2023.
  • American Society for Gastrointestinal Endoscopy (ASGE). Guideline. Endoscopic eradication therapy for patients with Barrett’s esophagus- associated dysplasia and intramucosal cancer. https://www.asge.org. Published April 2018. Accessed November 16, 2023.
  • American Society for Gastrointestinal Endoscopy (ASGE). Guideline. The role of endoscopy in the assessment and treatment of esophageal cancer. https://www.asge.org. Published 2013. Accessed November 16, 2023.
  • American Society of Breast Surgeons (ASBS).

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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.

  • American Society of Breast Surgeons. Consensus guideline on the use of transcutaneous and percutaneous ablation for the treatment of benign and malignant tumors of the breast. https://www.breastsurgeons.org. Published October 2018. Accessed November 16, 2023.
  • American Society of Clinical Oncology (ASCO). Clinically localized prostate cancer: ASCO clinical practice guideline endorsement of an American Urological Association/American Society for Radiation Oncology/Society of Urologic guideline. https://www.asco.org. Published November 10, 2018. Accessed November 16, 2023.
  • American Thyroid Association (ATA). 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer. https://www.thyroid.org. Published 2016. Accessed November 16, 2023.
  • American Thyroid Association (ATA). Revised American Thyroid Association guidelines for the management of medullary thyroid carcinoma. https://www.thyroid.org. Published 2015. Accessed November 16, 2023.
  • American Urological Association (AUA). Clinically localized prostate cancer: AUA/ASTRO guideline 2022. https://www.auanet.org. Published 2022. Accessed November 16, 2023.

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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.

  • American Urological Association (AUA). Renal mass and localized renal cancer: AUA guideline. https://www.auanet.org. Published April 2021. Accessed November 16, 2023.
  • Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). Cryosurgery of prostate (230.9). https://www.cms.gov. Published July 1, 2001. Accessed December 6, 2023.
  • ClinicalKey. Ferri F. Basal cell carcinoma. In: Ferri F. Ferri's Clinical Advisor 2024. Elsevier; 2024:245.e7.-245.e.10. https://www.clinicalkey.com. Accessed December 5, 2023.
  • ECRI Institute. Clinical Evidence Assessment. C2 cryoballoon ablation system (Pentax Medical, Inc.) for treating Barrett's esophagus or esophageal dysplasia. https://www.ecri.org. Published October 14, 2021. Accessed October 30, 2023.
  • ECRI Institute. Clinical Evidence Assessment. Cryoablation for treating prostate cancer. https://www.ecri.org. Published October 14, 2021. Accessed October 30, 2023.
  • ECRI Institute. Clinical Evidence Assessment. ICEfx cryoablation system (Boston Scientific Corp.) for treating renal cancer. https://www.ecri.org. Published September 15, 2023. Accessed October 30, 2023.
  • ECRI Institute. Clinical Evidence Assessment. truFreeze spray cryotherapy system (Steris Corp.) for Barrett's esophagus or esophageal cancer. https://www.ecri.org. Published May 20, 2014. Updated May 25, 2022. Accessed October 30, 2023.
  • ECRI Institute. Clinical Evidence Assessment. Visual-ICE cryoablation system (Boston Scientific Corp.) for treating early-stage or locally recurrent prostate cancer. https://www.ecri.org. Published July 25, 2016. Updated December 15, 2021. Accessed October 30, 2023.

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References

  • Hayes, Inc. Emerging Technology Report. ProSense system (IceCure Medical) for low-risk early-stage breast cancer. https://evidence.hayesinc.com. Published November 2, 2022. Updated November 1, 2023. Accessed December 7, 2023.
  • Hayes, Inc. Evidence Analysis Research Brief.
  • Hayes, Inc. Evidence Analysis Research Brief. Cryoablation for treatment of non-small cell lung cancer. https://evidence.hayesinc.com. Published April 26, 2022. Updated November 21, 2023. Accessed December 7, 2023.
  • Hayes, Inc. Evidence Analysis Research Brief. TruFreeze spray cryotherapy for treatment of Barrett’s esophagus. https://evidence.hayesinc.com. Published May 9, 2022. Accessed December 7, 2023.
  • Hayes, Inc. Medical Technology Directory (ARCHIVED). Comparative effectiveness review of cryoablation for primary treatment of localized prostate cancer. https://evidence.hayesinc.com. Published July 27, 2017. Updated September 13, 2021. Accessed December 7, 2023.
  • Hayes, Inc. Medical Technology Directory (ARCHIVED). Comparative effectiveness review of cryoablation for salvage treatment of recurrent prostate cancer following radiotherapy. https://evidence.hayesinc.com. Published July 27, 2017. Updated September 14, 2021. Accessed December 7, 2023.
  • Hayes, Inc. Medical Technology Directory (ARCHIVED). Percutaneous cryoablation for treatment of renal cell cancer. https://evidence.hayesinc.com. Published June 9, 2014. Updated May 8, 2018. Accessed October 30, 2023.
  • MCG Health. Cryotherapy, cervix. 27th edition.https://humanabh.access.mcg.com/index. Accessed October 17, 2023.
  • Merck Manual: Professional Version. Prostate cancer. https://www.merckmanuals.com. Updated October 2023. Accessed December 5, 2023.

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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.

  • Merck Manual: Professional Version. Retinoblastoma. https://www.merckmanuals.com. Updated October 2023. Accessed December 5, 2023.
  • National Cancer Institute (NCI). Childhood liver cancer treatment (PDQ) – health professional version. https://www.cancer.gov. Updated August 30, 2023. Accessed November 16, 2023.
  • National Cancer Institute (NCI). Colon cancer treatment (PDQ) – health professional version. https://www.cancer.gov. Updated October 18, 2023. Accessed November 16, 2023.
  • National Cancer Institute (NCI). Non-small cell lung cancer treatment (PDQ) – health professional version. https://www.cancer.gov. Updated February 17, 2023. Accessed November 16, 2023.
  • National Cancer Institute (NCI). Pancreatic neuroendocrine tumors (islet cell tumors) (PDQ) – health professional version. https://www.cancer.gov. Updated August 19, 2022. Accessed November 16, 2023.
  • National Cancer Institute (NCI). Pheochromocytoma and paraganglioma treatment (PDQ) – health professional version. https://www.cancer.gov. Updated August 25, 2022. Accessed November 16, 2023.
  • National Cancer Institute (NCI). Primary liver cancer treatment (PDQ) – health professional version. https://www.cancer.gov. Updated August 22, 2023. Accessed November 16, 2023.
  • National Cancer Institute (NCI). Prostate cancer treatment (PDQ) – health professional version. https://www.cancer.gov. Updated February 13, 2023. Accessed November 16, 2023.
  • National Cancer Institute (NCI). Rectal cancer treatment (PDQ) – health professional version. https://www.cancer.gov. Updated October 17, 2023. Accessed November 16, 2023.

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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.

  • National Cancer Institute (NCI). Retinoblastoma treatment (PDQ) – health professional version. https://www.cancer.gov. Updated April 11, 2023.
  • National Cancer Institute (NCI). Skin cancer treatment (PDQ) – health professional version. https://www.cancer.gov. Updated March 2, 2023. Accessed November 16, 2023.
  • National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Basal cell skin cancer. https://www.nccn.org. Updated September 14, 2023. Accessed December 6, 2023.
  • National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Bone cancer. https://www.nccn.org. Updated August 7, 2023. Accessed December 6, 2023.
  • National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Colon cancer. https://www.nccn.org. Updated November 16, 2023. Accessed December 6, 2023.
  • National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Esophageal and esophagogastric junction cancers. https://www.nccn.org. Updated August 29, 2023. Accessed December 6, 2023.
  • National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Hepatocellular carcinoma. https://www.nccn.org. Updated September 14, 2023. Accessed December 6, 2023.
  • National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Kaposi sarcoma. https://www.nccn.org. Updated November 7, 2023. Accessed December 7, 2023.
  • National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Kidney cancer. https://www.nccn.org. Updated June 21, 2023. Accessed December 6, 2023.

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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.

  • National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Neuroendocrine and adrenal tumors. https://www.nccn.org. Updated August 2, 2023. Accessed December 6, 2023.
  • National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Non-small cell lung cancer. https://www.nccn.org. Updated November 8, 2023. Accessed December 6, 2023.
  • National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Prostate cancer. https://www.nccn.org. Updated September 7, 2023. Accessed December 6, 2023.
  • National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Rectal cancer. https://www.nccn.org. Updated November 16, 2023. Accessed December 7, 2023.
  • National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Soft tissue sarcoma. https://www.nccn.org. Updated April 25, 2023. Accessed December 6, 2023.
  • National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Squamous cell skin cancer. https://www.nccn.org. Updated November 9, 2023. Accessed December 6, 2023.
  • National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Thyroid carcinoma. https://www.nccn.org. Updated April 25, 2023. Accessed December 6, 2023.
  • National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Uveal melanoma. https://www.nccn.org. Updated May 4, 2023. Accessed December 6, 2023.
  • Society of Interventional Radiology (SIR). Society of Interventional Radiology multidisciplinary position statement on percutaneous ablation of non-small cell lung cancer and metastatic disease to the lungs. https://sirweb.org. Published August 2021. Accessed November 16, 2023.

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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.

  • Society of Interventional Radiology (SIR). Society of Interventional Radiology position statement on percutaneous radiofrequency ablation for the treatment of liver tumors. https://sirweb.org. Published July 2009. Accessed November 16, 2023.
  • Society of Interventional Radiology (SIR). Society of Interventional Radiology position statement on the role of percutaneous ablation in renal cell carcinoma. https://sirweb.org. Published February 2020. Accessed November 16, 2023.
  • UpToDate, Inc. Assessment of tumor response in patients receiving systemic and nonsurgical locoregional treatment of hepatocellular cancer. https://www.uptodate.com. Updated October 27, 2023. Accessed November 15, 2023.
  • UpToDate, Inc. Barrett’s esophagus: surveillance and management. https://www.uptodate.com. Updated October 2023. Accessed November 21, 2023.
  • UpToDate, Inc. Bronchoscopic cryotechniques in adults. https://www.uptodate.com. Updated October 2023. Accessed November 15, 2023.
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Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0428-027
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Review Date: 12/14/2023
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Appendix B TNM Staging System for Prostate Cancer

Primary tumor (T) Clinical T (cT)

T category TX: Primary tumor cannot be assessed
T0: No evidence of primary tumor
T1: Clinically inapparent tumor that is not palpable
T1a: Tumor incidental histologic finding in 5% or less of tissue resected
T1b: Tumor incidental histologic finding in more than 5% of tissue resected
T1c: Tumor identified by needle biopsy found in one or both sides, but not palpable
T2: Tumor is palpable and confined within prostate
T2a: Tumor involves one-half of one side or less
T2b: Tumor involves more than one-half of one side but not both sides
T2c: Tumor involves both sides
T3: Extraprostatic tumor that is not fixed or does not invade adjacent structures
T3a: Extraprostatic extension (unilateral or bilateral)
T3b: Tumor invades seminal vesicle(s)
T4: Tumor is fixed or invades adjacent structures other than seminal vesicles such as external sphincter, rectum, bladder, levator muscles, and/or pelvic wall.

Pathological T (pT)

T category T2: Organ confined
T3: Extraprostatic extension
T3a: Extraprostatic extension (unilateral or bilateral) or microscopic invasion of bladder neck
T3b: Tumor invades seminal vesicle(s)
T4: Tumor is fixed or invades adjacent structures other than seminal vesicles such as external sphincter, rectum, bladder, levator muscles, and/or pelvic wall

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