CurrentBlue Cross Blue Shield - MassachusettsPolicy 633

Cryosurgical Ablation of Liver Tumors Policy

Policy governs coverage determination for cryosurgical ablation (open, laparoscopic, percutaneous) of primary or metastatic liver tumors for commercial and Medicare products, including inpatient preauthorization requirements and coding guidance. It states the technology is investigational and outpatient procedures are not covered for specified products.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyCryosurgical Ablation of Liver Tumors Policy

Policy CodePolicy 633

Change TypeAnnual review; literature and guideline updates

Effective Date

Next Review Date

Key ActionPrecertification/preauthorization is required for all products if cryosurgical ablation is performed inpatient.

SourceLink

POLICY UPDATE CHANGES

Annual policy review November 2025: policy updated with literature review through July 29, 2025; reference added; guidelines updated. Policy statement unchanged.

1Policy stance (Investigational)

3CPT codes listed

0Covered indications

Coverage Summary & Determination

This policy governs coverage determinations for cryosurgical ablation (CSA) of primary or metastatic liver tumors performed open, laparoscopically, or percutaneously, and applies to commercial and Medicare products with specified coding guidance (CPT codes 47371, 47381, and 47383). The technology is considered investigational and outpatient procedures are not covered for the listed products; inpatient procedures require precertification/preauthorization.