MA Radiofrequency Ablation or Transarterial Therapy for the Liver (Preauthorization Required)
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Preauthorization and coverage guidance for radiofrequency ablation (RFA) and arterially directed transarterial therapies (TAE, TACE, TARE) and related ablation techniques for hepatocellular carcinoma and liver metastases for Blue Cross Blue Shield - Nebraska members.
No material clinical or coverage changes in this revision.
Coverage Criteria
Medical necessity (referenced external criteria)
Coverage decisions rely on external Milliman/MCG clinical criteria and established guideline literature to determine medical necessity for hepatic ablative and arterially directed therapies.
The policy defers to MCG for specific eligibility criteria, appropriateness determinations, and detailed patient selection guidance.
Coverage determinations for radiofrequency ablation and arterially directed transarterial therapies of the liver are made by applying the procedure codes listed in this policy together with external clinical guidance. Use the listed CPT codes (for example, 37242, 37243, 47370, 47380, 47382, 47383, 76940) in conjunction with the Milliman/MCG clinical criteria referenced by this policy to determine medical necessity and appropriateness for individual members. The policy explicitly directs reviewers to the MCG resources for specific eligibility and clinical decision rules.
This policy does not enumerate discrete ‘‘not medically necessary’’ exclusions within the document text. Instead, determinations that a requested service is not medically necessary should be based on the MCG clinical criteria and applicable guideline literature cited by the policy, applied to the member’s clinical presentation and the specific CPT code(s) submitted.
Covered Indications
Hepatocellular carcinoma and liver metastases
Covered when the treatment of hepatocellular carcinoma (HCC) or liver metastases is appropriate according to clinical guidelines and Milliman/MCG criteria.
Refer to MCG and guideline references (ACR, NCCN, Lancet) for indication-level eligibility, staging considerations, and selection between modalities.
Coding
Provider Actions
Preauthorization required for RFA and transarterial therapies
Preauthorization is required for radiofrequency ablation and arterially directed transarterial therapies of the liver. Submit prior authorization requests using the payer's preauthorization process and reference MCG clinical criteria as applicable.
- Applies to procedures listed in the policy (see CPT codes in policy).
- Contact umanagement@p3hp.org for access to MCG if needed.
No step therapy program specified
This policy does not impose a step therapy program or a required stepwise treatment sequence. Appropriateness and eligibility are determined by referenced clinical criteria (Milliman/MCG) and guideline literature.
Reference MCG criteria and include listed CPT codes
Preauthorization requests should reference the Milliman/MCG clinical criteria and include the relevant procedure CPT codes as listed in the policy.
Risk of denial if procedure submitted without paired diagnosis or proper code-pair
Procedures submitted without an associated diagnosis code or without using the policy's Quick Code Search code-pair process may be at risk for denial or held for review.
- Use the Quick Code Search to add a procedure + diagnosis code pair before submission.
- Enter at least the first three characters of the procedure and diagnosis codes when using the Quick Code Search.
Definitions
Background
Hepatocellular carcinoma (HCC) and liver metastases can be managed surgically or with locoregional therapies that induce tumor necrosis when resection is not feasible. Treatment options include surgical resection and percutaneous or surgical ablative approaches as well as catheter-directed, arterially delivered therapies. Ablative techniques encompass chemical methods (for example, percutaneous ethanol injection), thermal methods such as radiofrequency ablation and microwave ablation, cryoablation, and irreversible electroporation. Transarterial therapies include bland embolization (TAE), chemoembolization (TACE), and radioembolization (TARE) using yttrium-90 microspheres. These modalities are considered per clinical guideline recommendations and the Milliman/MCG criteria when selecting appropriate candidates for locoregional liver therapy.
Prior Authorization
Preauthorization required prior to service for listed procedures
All listed interventional ablation and transarterial procedures for the liver require preauthorization prior to the service being performed.
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