DraftBlue Cross Blue Shield - Rhode IslandPolicy N/A

Cryosurgical Ablation of Miscellaneous Solid Tumors other than Renal, Liver and Prostate

Governs coverage and medical necessity criteria for cryosurgical ablation (cryoablation) of miscellaneous solid tumors such as lung, breast, pancreas, and bone for Blue Cross Blue Shield - Rhode Island members.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyCryosurgical Ablation of Miscellaneous Solid Tumors other than Renal, Liver and Prostate

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2019

Next Review Date

Key ActionObtain prior authorization for BlueCHiP for Medicare (recommended for Commercial products) before performing cryosurgical ablation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1Covered CPT procedure for pulmonary cryoablation listed

2Not covered CPT codes (breast, bone)

4Anatomic tumor sites discussed

1Prior authorization statement

Coverage and Medical Necessity Criteria

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Medically Necessary — Lung (BlueCHiP for Medicare)

Cryosurgical ablation may be considered medically necessary when ALL of the following BlueCHiP for Medicare criteria are met:

BlueCHiP for Medicare lung criteria: Patient has early-stage non-small-cell lung cancer and is a poor surgical candidate OR the patient requires palliation for a central airway obstructing lesion.

Applies to BlueCHiP for Medicare; prior authorization is required for BlueCHiP for Medicare (see provider actions).

Cryosurgical ablation of tumors of the breast, pancreas, bone and other miscellaneous solid tumors or metastases (outside the liver, prostate, and renal sites) is considered not covered / not medically necessary due to insufficient evidence of clinical benefit. Specific procedure codes for these indications (for example, cryoablation of fibroadenoma and bone tumor cryoablation) are listed as not covered.

Benefits and coverage determinations under this policy are subject to the member's subscriber agreement, member certificate, or employer agreement, which supersede this medical policy. Providers should verify member-specific benefits and eligibility by contacting the provider call center; this policy is informational and is not a guarantee of payment.

Cryosurgical ablation for breast tumors (including fibroadenomas), pancreatic tumors, bone tumors, and other miscellaneous solid tumors or metastases outside of the liver, prostate, or kidney is considered not medically necessary / not covered. The policy explicitly lists CPT codes 19105 (cryoablation of fibroadenoma) and 20983 (percutaneous cryoablation of bone tumors) among the procedures not covered for these indications.

Billing and Procedure Codes

Covered CPT CodesCPTCovered

32994

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

Not Covered / Not Medically Necessary CPT CodesCPTNot Covered

19105	Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma
20983	Ablation therapy for reduction Or eradication of 1 O1 more bone tumors (eg, metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; cryoablation

Provider Requirements, Authorization, and Billing Risk

Prior Authorization

Prior Authorization Required

Prior authorization is required for BlueCHiP for Medicare and recommended for Commercial Products for cryosurgical ablation as a treatment of cancer.

Note

Verify Benefits and Eligibility

Provider should verify member-specific benefits and eligibility before providing services. For member-specific benefit information, contact the provider call center.

Step Therapy

No step therapy requirements specified for this service.

Documentation Required

Benefit Verification / Governing Documents

Refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicability of benefits; benefits and eligibility are determined by the member's subscriber/employer agreements which supersede this policy.

Denial Risk

Not Covered / Denial Risk for Specific CPT Codes

The following CPT codes are listed as not covered for BlueCHiP for Medicare and not medically necessary for Commercial Products and may be denied if billed: 19105 — Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma; 20983 — Ablation therapy for reduction or eradication of one or more bone tumors (eg, metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; cryoablation.

CPT 19105
CPT 20983

Billing Rule

Member Financial Responsibility When Not Covered

If services are determined to be not medically necessary or are non-covered benefits, the provider may not charge the member unless the member has been informed and has agreed in writing in advance to accept financial responsibility. Refer to your participation agreement for applicable provisions.

Background and Clinical Context

Cryosurgical ablation (cryoablation) is a technique that destroys target tissue by freezing via probes that carry a coolant. Procedures may be performed as open surgery, laparoscopic approaches, or percutaneously using imaging guidance. The evidence base for cryoablation in many non‑hepatic, non‑prostatic indications consists largely of small, nonrandomized studies with limited follow-up, and these limitations have informed the policy’s coverage determinations.

Definitions and Terminology

Cryosurgical ablation — definition

DefinitionCryosurgical ablation (cryoablation) involves freezing of target tissues via coolant-carrying probes and may be performed as an open surgical technique or as a closed percutaneous/laparoscopic procedure with imaging guidance.

Typical approachesPerformed as open surgery, laparoscopic procedure, or percutaneous (closed) technique with imaging guidance (eg, ultrasound, CT).

InstrumentationUses coolant-carrying probes inserted into the tumor to achieve tissue freezing (cryotherapy).

Indications contextDescribed in this policy for miscellaneous solid tumors located in sites such as breast, bone, pancreas and lung (see coverage criteria for site-specific guidance).

Cryoablation / Cryosurgery — brief

TechniqueCryoablation / cryosurgery is a minimally invasive thermal ablation technique that uses freezing (cryotherapy) applied percutaneously or via office-based approaches.

Clinical uses describedApplied in the literature for treatment of benign and malignant breast lesions (including fibroadenomas), pancreatic tumors, bone tumors, and metastatic lesions.

Evidence baseEvidence consists of multiple case series, trials, and systematic reviews cited in the policy references (see listed studies on breast, pancreas, and bone cryoablation).

SettingsMay be performed in percutaneous image-guided or office-based settings depending on lesion type and protocol described in referenced studies.