CurrentBlue Cross Blue Shield of KansasPolicy N/A

Cryosurgical Ablation of Primary or Metastatic Liver Tumors

Blue Cross Blue Shield of Kansas policy addressing the evidence, coding, and coverage stance for cryosurgical ablation of primary and metastatic liver tumors (including colorectal metastases, hepatocellular carcinoma, neuroendocrine metastases), with rationale, supplemental guidelines, and coding lists.

Policy Summary

PayerBlue Cross Blue Shield of Kansas

PolicyCryosurgical Ablation of Primary or Metastatic Liver Tumors

Policy CodePolicy N/A

Change TypeInvestigational (since 06-12-2015)

Effective DateJune 12, 2015

Next Review Date

Key ActionClaims for cryosurgical ablation of primary or metastatic liver tumors should be supported by documentation; expect denial because the procedure is designated experimental/investigational unless contract or future policy changes indicate otherwise.

POLICY UPDATE CHANGES

06-12-2015 policy position changed to: 'Cryosurgical ablation of either primary or metastatic tumors in the liver is experimental / investigational.'

10-24-2023 removed ICD-10 Diagnoses Box from Coding section and updated references.

Multiple update entries through 10-28-2025 and 10-22-2024 reflecting updates to Description, Rationale, and References.

1Randomized trial meeting criteria (Korpan 1997)

multipleNonrandomized series and case studies reviewed

2015-06-12Date policy stance changed to investigational

Coverage Summary & Policy Stance

Scope: Payer: Blue Cross Blue Shield of Kansas. Subject: Cryosurgical ablation / cryoablation of primary and metastatic liver tumors (including colorectal metastases, hepatocellular carcinoma, and neuroendocrine metastases). Coverage stance: As of 2015-06-12 the policy position is that "Cryosurgical ablation of either primary or metastatic tumors in the liver is experimental / investigational." This investigational stance was implemented on 06-12-2015 and has been maintained in subsequent reviews (last_review: 2025-10-28); policy status is CURRENT. Historical policy language previously allowed selected medically necessary uses (e.g., for some HCC, colorectal metastases, or symptomatic neuroendocrine metastases) but these were superseded by the 06-12-2015 revision.

Policy Criteria

Policy Position (as of 06-12-2015 and maintained thereafter)

Policy statements and historical medically necessary / investigational positions reflected in revision history:

Cryosurgical ablation of either primary or metastatic tumors in the liver is experimental / investigational.

Prior policy statements (historical, prior to 06-12-2015)

Earlier positions that were superseded by 06-12-2015 revision (included for supplemental context):

Cryosurgical ablation of primary hepatocellular carcinoma (HCC) may be considered medically necessary as a primary treatment of HCC for patients when all tumor foci can be adequately treated.

Cryosurgical ablation of primary HCC is medically necessary as a bridge to transplant to maintain transplant candidacy.

Cryosurgical ablation of primary HCC is investigational when not all sites of tumor foci can be adequately treated.

Cryosurgical ablation may be considered medically necessary as a primary treatment of hepatic metastases from colorectal cancer in the absence of extrahepatic metastatic disease when all tumor foci can be adequately treated.

Cryosurgical ablation may be considered medically necessary as treatment of hepatic metastases from neuroendocrine tumors in patients with symptomatic disease.

Cryosurgical ablation for hepatic metastasis is considered experimental / investigational for: 1) hepatic metastases from colorectal cancer or neuroendocrine tumors that do not meet the criteria above; and 2) hepatic metastases from other types of cancer (except colorectal).

Provider Responsibilities & Billing Impact

Denial Risk

Experimental/Investigational Coverage Determination

Claims for cryosurgical ablation of primary or metastatic liver tumors should be supported by documentation; however, as the policy position states cryosurgical ablation is considered experimental/investigational and thus not covered, providers should expect denial unless otherwise indicated by contract or future policy change.

47371
47381
47383
76940

Billing Rule

Coding Informational Use Only

The listed CPT codes are provided for informational purposes; inclusion does not imply member coverage or provider reimbursement and are medically necessary ONLY if performed according to the policy section (which designates cryosurgery as experimental/investigational).

Relevant Codes (Informational)

Informational / Applicable CPTCPT

47371	Laparoscopy, surgical, ablation of 1 or more liver tumor(s); cryosurgical.
47381	Ablation, open, of 1 or more liver tumor(s); cryosurgical.
47383	Ablation, 1 or more liver tumor(s), percutaneous, cryoablation.
76940	Ultrasound guidance for, and monitoring of, parenchymal tissue ablation.

Evidence Summary & Rationale

Evidence review scope: the review evaluated randomized controlled trials (including the Wang et al RCT comparing cryoablation with RFA), nonrandomized comparative studies, single-arm series, and systematic reviews/meta-analyses. Supplemental inputs included practice guideline excerpts from NCCN and listings of ongoing clinical trials. Overall rationale for the investigational stance: evidence shows limited and heterogeneous data — a single RCT and multiple nonrandomized studies and meta-analyses with variable results and methodologic limitations, and safety concerns (including procedure-related mortality and cryoshock) — leading to the conclusion that evidence is insufficient to establish that cryoablation improves net health outcomes compared with other locoregional therapies.

Definitions

Definitions: Cryosurgical ablation / cryoablation: "A local ablative technique using extreme cold to destroy tumor tissue in the liver performed percutaneously, laparoscopically, or via open surgery."

Policy Revision Timeline

06-12-2015policy_revision

Policy position changed to: 'Cryosurgical ablation of either primary or metastatic tumors in the liver is experimental / investigational.' Detail: Replaced prior medically-necessary allowances for selected HCC, colorectal metastases, and neuroendocrine metastases with an investigational stance. Highlighted as a material/key policy stance change.

10-24-2023administrative_update

Administrative/coding format change: removed ICD-10 Diagnoses Box from Coding section and updated references. No clinical policy statement change.

10-22-2024routine_update

Routine updates to Description, Rationale, and References; policy clinical stance remained investigational since 06-12-2015.