CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Microwave Ablation Policy

Defines medical necessity criteria, coverage limitations, prior authorization expectations, and billing guidance for microwave ablation of tumors (primarily liver and lung) for BCBSRI Medicare Advantage and Commercial members.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMicrowave Ablation Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb 1, 2020

Next Review Date

Key ActionPrior authorization is required for Medicare Advantage members and recommended for Commercial products; document unresectability and tumor size/number per eligibility thresholds.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes

2Tumor sites with coverage criteria (liver, lung)

1Covered HCPCS code

>1CPT coding approach

Coverage Summary

Microwave Ablation (MWA) is a thermal ablation technique that uses microwave energy to induce coagulation and localized tissue necrosis and may be performed percutaneously, laparoscopically, thoracoscopically, or open. Coverage stance is mixed, with specific medically necessary criteria for treating tumors of the liver and the lung. Effective date: 02/01/2020; Last review: 10/20/2021; Status: CURRENT.

Medical-Necessity Criteria

Medically Necessary / Covered for Hepatic Tumors

Microwave ablation of primary or metastatic hepatic tumors may be considered covered when ALL of the following are met:

ALL of the following

Tumor is unresectable due to location of lesion(s) and/or comorbid conditions
Tumor burden meets size/number criteriasingle tumor ≤ 5 cm OR up to 3 nodules <3 cm each

Medically Necessary / Covered for Lung Tumors

Microwave ablation of primary or metastatic lung tumors may be considered covered when ALL of the following are met:

ALL of the following

Tumor is unresectable due to location of lesion and/or comorbid conditions
Single tumor ≤ 3 cmsingle tumor ≤ 3 cm

Not Covered / Not Medically Necessary

Limitations and noncovered indications for Medicare Advantage and Commercial products:

ANY of the following

Microwave ablation of more than a single primary or metastatic tumor in the lung
Considered not covered for Medicare Advantage Plans and not medically necessary for Commercial
Microwave ablation of primary or metastatic tumors other than liver or lung
Considered not covered for Medicare Advantage Plans and not medically necessary for Commercial

Coding

Related HCPCS code covered if criteria metHCPCSCovered

C9751

Bronchoscopy, rigid or flexible, transbronchial ablation of lesion(s) by microwave energy, including fluoroscopic guidance, with CT acquisition(s) and 3-D rendering, computer-assisted image-guided navigation, and endobronchial ultrasound guided sampling and therapeutic interventions

Procedure coding instructionCPT

unlisted

No CPT codes specific to microwave tumor ablation; report the unlisted CPT code for the anatomic area

Billing Rule

Use unlisted CPT for anatomic area

Report the unlisted CPT code for the anatomic area for microwave tumor ablation. When the procedure is performed via bronchoscopy with the specified features, report HCPCS C9751.

C9751
unlisted

Provider Actions

Prior Authorization

Prior authorization required for Medicare Advantage

Prior authorization is required for Medicare Advantage Plan members.

Prior Authorization

Prior authorization recommended for Commercial

Prior authorization is recommended for Commercial products.

Documentation Required

Document unresectability and tumor characteristics

Document that the tumor is unresectable due to lesion location and/or patient comorbid conditions and document tumor size and number consistent with the eligibility thresholds (hepatic: single tumor ≤ 5 cm or up to 3 nodules < 3 cm each; lung: single tumor ≤ 3 cm).

Background & Evidence

MWA thermally coagulates tissue by delivering microwave energy via one or more antennas inserted directly into the tumor; energy causes water-molecule rotation and rapid heating to create localized coagulation and necrosis. The procedure can be done percutaneously, laparoscopically, thoracoscopically, or as an open surgical approach under image guidance (eg, ultrasound, CT, MRI) with sedation or anesthesia.

Evidence supports MWA as an effective option versus radiofrequency ablation (RFA) and resection for unresectable hepatic tumors meeting size/number thresholds (single tumor ≤ 5 cm or up to 3 nodules < 3 cm each), with RCTs, comparative observational studies, and systematic reviews showing similar survival outcomes in selected patients. For lung tumors, there is one RCT and observational data showing effectiveness for single tumors ≤ 3 cm, but evidence is insufficient to support MWA for multiple pulmonary tumors or for tumors in organs other than liver or lung.

Prior authorization expectations and coding guidance apply (prior authorization required for Medicare Advantage and recommended for Commercial; report unlisted CPT code for the anatomic area and HCPCS C9751 when applicable).

Evidence area	Summary
Hepatic evidence	RCTs, comparative observational studies, and systematic reviews showing MWA effective vs RFA and resection in unresectable hepatic tumors meeting size/number criteria (single tumor ≤5 cm or up to 3 nodules <3 cm)
Lung evidence	One RCT and observational studies show MWA effective for unresectable single lung tumors (evidence sufficient only for single tumors ≤3 cm); studies limited for multiple tumors
Other tumors evidence	Insufficient evidence for renal and other non-hepatic/non-pulmonary tumors to determine improvement in net health outcome

Definitions

UnresectableTumor not amenable to surgical resection due to lesion location and/or patient comorbid conditions

Microwave Ablation (MWA)A thermal ablation technique using microwave energy (typically 915 MHz or 2.45 GHz) via antennae to induce coagulation and tissue necrosis