Irreversible Electroporation (IRE) of Tumors Other Than Liver
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This draft policy addresses coverage and prior authorization for irreversible electroporation (IRE) when used to treat non-liver primary or metastatic solid tumors (e.g., pancreas, kidney, lung, prostate) for Blue Cross Blue Shield - Rhode Island Medicare Advantage and Commercial products.
Prior authorization is required for CPT code 0601T for Medicare Advantage Plans and recommended for Commercial Products.
IRE for treatment of primary or metastatic solid tumors other than liver is considered not covered for Medicare Advantage Plans and not medically necessary for Commercial Products.
CPT code 55877 (Ablation, irreversible electroporation, prostate, percutaneous) is listed as not covered / not medically necessary when used for tumors other than liver.
CPT code 0600T text was revised effective 1/1/2026 and is listed as not covered / not medically necessary for IRE of tumors other than liver.
CPT code 0601T (open approach) is listed as not covered / not medically necessary when filed for IRE of tumors other than liver.
Coverage Determinations and Scope
Coverage Determination
Policy statement for Medicare Advantage Plans and Commercial Products
Evidence is insufficient to determine that the technology results in an improvement in the net health outcome.
This policy specifically excludes irreversible electroporation (IRE) of tumors of the liver. For IRE procedures involving the liver, refer to the Related Policies section and the separate liver-specific coverage policy; liver IRE is not addressed in this document.
For Blue Cross Blue Shield - Rhode Island Medicare Advantage Plans and Commercial Products, IRE used to treat primary or metastatic solid tumors other than liver (including but not limited to pancreas, kidney, lung, or prostate) is considered not covered for Medicare Advantage and not medically necessary for Commercial products due to insufficient evidence of improvement in net health outcome.
Procedure Codes and Coverage Status
| 0601T | Ablation, irreversible electroporation; 1 or more tumors per organ, including fluoroscopic and ultrasound guidance, when performed, open |
| 55877 | Ablation, irreversible electroporation, prostate, 1 or more tumors, including imaging guidance, percutaneous (New Code Effective 1/1/2026) |
| 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 |
Authorization, Documentation, and Billing Guidance
Prior authorization reference — see related policy
Refer to the payer's Prior Authorization of Services, Treatments or Procedures policy for any authorization requirements related to irreversible electroporation procedures and listed CPT codes.
- Related policy: Prior Authorization of Services, Treatments or Procedures
Step therapy — none specified
No step therapy requirements are specified in this policy document for irreversible electroporation of tumors other than liver.
Step therapy — none specified (document segment)
No step therapy requirements are specified in this document segment.
Prior authorization and documentation for CPT 0601T
Obtain prior authorization for CPT 0601T for Medicare Advantage (required) and consider obtaining authorization for Commercial members (recommended). Documentation should support medical necessity, but the policy states IRE for non-liver tumors is generally not covered/not medically necessary.
- Prior authorization: required for Medicare Advantage for CPT 0601T; recommended for Commercial.
- Documentation must support medical necessity though policy indicates IRE for non-liver tumors is not covered/not medically necessary.
Documentation and benefit verification required
Verify member benefits and eligibility prior to service; benefits are determined by the member's subscriber agreement or employer agreement and supersede this policy. For member-specific benefits, contact the provider call center.
- Benefits and eligibility determined by subscriber agreement or employer agreement.
- Contact provider call center for member-specific benefit information.
Coverage denial risk for IRE of non-liver tumors
Irreversible electroporation (IRE) for treatment of primary or metastatic solid tumors other than liver is considered not covered for Medicare Advantage Plans and not medically necessary for Commercial Products; claims may be denied on that basis.
- Coverage stance: not covered for Medicare Advantage; not medically necessary for Commercial.
Denial risk for specific CPT codes (55877, 0600T, 0601T)
Claims billed with CPT codes 55877, 0600T, or 0601T for irreversible electroporation of tumors other than liver are not covered for Medicare Advantage Plans and are not medically necessary for Commercial Products and may be denied.
- 55877 — Ablation, irreversible electroporation, prostate, percutaneous (new code effective 1/1/2026).
- 0600T — Ablation, irreversible electroporation; percutaneous for tumors per organ other than liver or prostate (text revised effective 1/1/2026).
- 0601T — Ablation, irreversible electroporation; open approach (listed as not covered when filed for tumors other than liver).
Clinical Background and Rationale
Irreversible electroporation (IRE) delivers high-frequency electric pulses to create an electric field that permanently disrupts cell membranes, causing cell death without a thermal effect. Because IRE does not rely on thermal injury, it may preserve adjacent structures such as blood vessels, nerves, and extracellular matrix. IRE is being investigated as a locoregional treatment for non-liver solid tumors (for example, pancreas, kidney, lung, and prostate), but available evidence is limited and predominantly from single-arm studies, and comparative and long-term outcome data are insufficient to establish improved net health outcomes.
Key Terms and Device Information
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