CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Irreversible Electroporation (IRE) of Tumors Other Than Liver

Defines coverage, prior authorization, and medical necessity stance for IRE procedures performed for tumors other than the liver for Medicare Advantage and Commercial products of the payer.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyIrreversible Electroporation (IRE) of Tumors Other Than Liver

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 1, 2026

Next Review DateFeb 18, 2026

Key ActionObtain prior authorization for CPT 0601T (required for Medicare Advantage; recommended for Commercial).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not covered/NMNNon-liver IRE stance

0601TPrior auth code

55877Prostate IRE code

MultipleTumor sites reviewed

58References

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Not covered / Not medically necessary

Covered when ALL of the following are met:

Primary statement: Irreversible electroporation (IRE) for treatment of primary or metastatic solid tumors including, but not limited to, tumors of the pancreas, kidney, lung or prostate is considered not covered for Medicare Advantage Plans and not medically necessary for Commercial Products.

Evidence insufficient to demonstrate improved net health outcome; see organ-specific evidence summaries.

The following CPT code(s) are not covered for Medicare Advantage Plans and not medically necessary for Commercial Products when filed for irreversible electroporation (IRE) of tumors other than the liver: 0601T (Ablation, irreversible electroporation; 1 or more tumors per organ, including fluoroscopic and ultrasound guidance, when performed, open).

Irreversible electroporation (IRE) for treatment of primary or metastatic solid tumors, including but not limited to tumors of the pancreas, kidney, lung, and prostate, is considered not covered for Medicare Advantage Plans and not medically necessary for Commercial Products due to insufficient evidence of improved net health outcome.

Procedure Codes and Coding Notes

Prostate IRE (listed as not covered/not medically necessary)CPTNot Covered

55877

Ablation, irreversible electroporation, prostate, 1 or more tumors, including imaging guidance, percutaneous (New Code Effective 1/1/2026)

Non-liver IRE CPT codesCPTNot Covered

0600T	Ablation, irreversible electroporation; 1 or more tumors per organ, other than liver or prostate, including imaging guidance, when performed, percutaneous (Text Revised Effective 1/1/2026)
0601T	Ablation, irreversible electroporation; 1 or more tumors per organ, including fluoroscopic and ultrasound guidance, when performed, open

Provider Requirements and Billing Actions

Prior Authorization

Prior Authorization Required for CPT 0601T

Prior Authorization is required for CPT code 0601T for Medicare Advantage plans and is recommended for Commercial products. This code is not specific to tumor location (e.g., liver, pancreas, kidney, lung, prostate).

Affected code: CPT 0601T
Prior authorization required: Medicare Advantage Plans
Prior authorization recommended: Commercial Products

Note

Confirm Benefits / Eligibility

Benefits and coverage may vary by contract. Providers should verify member-specific benefits and eligibility before providing services. Refer to the member's Evidence of Coverage or Subscriber Agreement for applicable surgical benefits and coverage.

Check Evidence of Coverage or Subscriber Agreement
For member-specific benefits, call the provider call center

Note

Benefit Verification

Providers must verify benefits and coverage prior to rendering services because benefits and requirements can vary by contract. For member-specific benefit information, consult the subscriber agreement or call the provider call center.

Verify benefits: Evidence of Coverage or Subscriber Agreement
Contact: Provider call center for member-specific questions

Denial Risk

Potential Denial Risk for Non‑Covered or Not Medically Necessary Services

Services determined to be not medically necessary or non-covered may be denied and could result in financial liability to the member or provider if performed without documented informed consent for self-pay. Providers must inform members and obtain written agreement before proceeding with non-covered services.

Claims for IRE of non-liver tumors (e.g., pancreas, kidney, lung, prostate) may be denied or considered not medically necessary
If service is non-covered or NMN, provider may not charge member unless the member has been informed and agreed in writing to self-pay

Background and Rationale

Irreversible electroporation (IRE) is a non-thermal ablation technique that delivers high-frequency electric pulses between electrodes to create an electric field that permanently disrupts cell membranes and causes cell death while preserving surrounding structural tissues such as blood vessels, nerves, and extracellular matrix. It is being investigated as a locoregional therapy for tumors in situations where thermal ablation may risk adjacent critical structures, but current evidence for non-liver indications relies primarily on single-arm observational studies and systematic reviews without sufficient comparative data to demonstrate improved net health outcomes.

Key Definitions

Irreversible electroporation (IRE) — definition and brief description

DefinitionIrreversible electroporation (IRE) is a non‑thermal ablation technique that uses high‑frequency electric pulses between electrodes to create an electric current that permanently damages cell membranes, causing cell death due to loss of homeostasis.

Mechanism of actionProduces no thermal effect and induces permanent membrane disruption rather than heating, allowing cell death while potentially preserving surrounding vessels, nerves, and the extracellular matrix.

Distinction from reversible electroporationElectroporation may be reversible or irreversible; IRE refers specifically to permanent membrane damage and cell death rather than transient membrane permeability.

Clinical contextInvestigational as a locoregional tumor ablation approach for non‑liver solid tumors (e.g., pancreas, kidney, lung, prostate) where thermal injury to adjacent structures is a concern.

Scope noteThis policy excludes IRE for liver tumors; refer to related policies for liver indications.

Therapy Line and Usage

salvage

Salvage or adjunct use context: IRE may be considered in salvage or adjunct local therapy settings (for example, focal therapy for recurrent prostate cancer after radiation or as adjunctive local therapy in locally advanced pancreatic cancer after systemic therapy), but such use is investigational and is not covered or considered medically necessary under this policy.

No line-of-therapy coverage is approved; see organ-specific evidence summaries and NCCN guidance noting IRE as experimental or for clinical trials.