CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

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

BCBSRI policy governing medical necessity and coverage for cryosurgical ablation (cryoablation) of miscellaneous solid tumors located in breast, bone, pancreas, and lung, excluding renal, liver, and prostate tumors. It specifies covered indications for lung tumors, noncoverage for breast/pancreas/bone, prior authorization requirements, and associated CPT/HCPCS coding guidance.

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 TypeClarified

Effective DateDec 1, 2021

Next Review Date

Key ActionPrior authorization is required for Medicare Advantage Plans and recommended for Commercial Products; document that the patient is a poor surgical candidate or requires palliation for a central airway obstructing lesion to meet medical necessity for lung tumor cryoablation.

SourceLink

POLICY UPDATE CHANGES

Policy defines cryoablation as medically necessary for specific lung cancer situations and not medically necessary for breast, pancreas, and bone tumors.

1Covered Indications (lung)

3Non-covered Tumor Sites

1Covered CPT code

Coverage Summary

This policy defines cryosurgical ablation as medically necessary for specific lung cancer indications — namely, early-stage non–small-cell lung cancer in patients who are poor surgical candidates or for palliation of a central airway–obstructing lesion — and requires prior authorization for Medicare Advantage plans (recommended for commercial products). It also states that cryoablation is not medically necessary / not covered for tumors of the breast, pancreas, and bone because the evidence is insufficient to determine effects on health outcomes.

Renal, liver, and prostate tumors are excluded from this policy and are addressed in separate related policies.

effective2021-12-01

last_review2025-08-06

next_review

statusCURRENT

confidence0.92

subjectCryosurgical ablation of miscellaneous solid tumors (excluding liver, prostate, renal)

Medical-Necessity Criteria

Medically Necessary - Lung Tumors

Cryosurgical ablation may be considered medically necessary to treat lung cancer when ONE of the following is met:

Early-stage NSCLC - poor surgical candidate: The individual has early-stage non-small-cell lung cancer and is a poor surgical candidate
Palliation for central airway obstruction: The individual requires palliation for a central airway obstructing lesion

Not Medically Necessary / Not Covered - Breast, Pancreas, Bone and Other Miscellaneous Solid Tumors

Cryosurgical ablation is not covered / not medically necessary for the following tumor sites because evidence is insufficient to determine effects on health outcomes:

Coding

Covered when criteria metCPTCovered

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 necessaryCPT|HCPCSNot Covered

19105	Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma
20983	Ablation therapy for reduction or eradication of 1 or more bone tumors (eg, metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; cryoablation
0581T	Ablation, malignant breast tumor(s), percutaneous, cryotherapy, including imaging guidance when performed, unilateral

Required Provider Actions

Prior Authorization

Prior authorization requirement

Prior authorization is required for Medicare Advantage Plans and recommended for Commercial Products for cryosurgical ablation as a treatment of lung cancer. Providers should obtain prior authorization when billing for the listed CPT code.

Affected code: 32994
Prior authorization: required for Medicare Advantage; recommended for Commercial

Documentation Required

Document surgical candidacy and indication

For lung tumor coverage, providers must document that the patient meets the medical necessity criteria — either the patient is a poor surgical candidate for early-stage non-small-cell lung cancer or requires palliation for a central airway obstructing lesion. This documentation should be included to support medical necessity when billing the applicable code.

Background and Evidence

Cryosurgical ablation (cryoablation) is a technique that involves freezing target tissues, most often by inserting a coolant-carrying probe into the tumor. It may be performed percutaneously, laparoscopically, or as an open surgical procedure under imaging or ultrasound guidance. This policy covers miscellaneous solid tumors in sites such as the breast, bone, pancreas, and lung, but excludes renal, liver, and prostate tumors which are covered under separate policies.

The evidence base consists primarily of uncontrolled observational studies and case series; randomized controlled trials and comparative data are lacking. For lung tumors the available data are small cohort and nonrandomized studies with short follow-up, limiting conclusions about net health outcomes. For breast, pancreas, and bone tumors the evidence is similarly limited or insufficient to determine benefit on health outcomes.

Cryosurgical ablation / cryoablationProcedure involving freezing of target tissues, often via insertion of a coolant-carrying probe, performed open, laparoscopically, or percutaneously with imaging guidance.

Revision History

2021-12-01policy_effective

Policy effective date recorded for Cryosurgical Ablation of Miscellaneous Solid Tumors other than Renal, Liver and Prostate.

2021-12-01coverage_definition

Defines cryosurgical ablation/ cryoablation as freezing target tissues using a coolant-carrying probe; may be performed open, laparoscopically, or percutaneously with imaging guidance.

2021-12-01medically_necessary

Cryosurgical ablation may be considered medically necessary to treat lung cancer when ONE of the following is met: early-stage non-small-cell lung cancer in a poor surgical candidate, or palliation for a central airway obstructing lesion; prior authorization required for Medicare Advantage and recommended for Commercial Products.

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 TypeClarified

Effective DateDec 1, 2021

Next Review Date

SourceLink

On This Page

Breast tumors: Benign or malignant tumors of the breast (including fibroadenomas and primary/recurrent breast cancer) - not covered/not medically necessary

Pancreatic tumors: Benign or malignant tumors of the pancreas - not covered/not medically necessary

Bone tumors: Primary bone cancers and bone metastases (bone tumors) - not covered/not medically necessary

Other solid tumors outside liver/prostate/renal: Other solid tumors or metastases outside the liver, prostate, or renal tumor - not covered/not medically necessary

Required documentation: poor surgical candidate for early-stage non-small-cell lung cancer OR need for palliation of a central airway obstructing lesion
Affected code: 32994

Denial Risk

Denial for excluded tumor sites

Claims for cryoablation of tumors at excluded sites will be denied or are not covered because the evidence is insufficient to determine effects on health outcomes for these tumor sites.

Affected codes: 19105, 20983, 0581T
Claims for breast, pancreas, bone, and other excluded solid tumor sites (outside liver, prostate, renal) will be denied/not covered

2021-12-01not_medically_necessary

Cryosurgical ablation is not covered / not medically necessary for benign or malignant tumors of the breast (including fibroadenomas and primary/recurrent breast cancer), benign or malignant tumors of the pancreas, and primary bone cancers and bone metastases, and other solid tumors or metastases outside the liver, prostate, or renal tumor due to insufficient evidence.

2021-12-01coding_update

Covered CPT code when criteria met: 32994 (cryoablation of pulmonary tumor[s]); Not covered / not medically necessary codes: 19105 (breast fibroadenoma cryoablation), 20983 (bone tumor cryoablation), 0581T (percutaneous malignant breast tumor cryotherapy).

2024-11-01provider_update_published

Provider Update published November 2024 (listed in published provider updates).

2025-10-01provider_update_publishedLatest

Most recent Provider Update published October 2025. Revision history indicates no clinical policy statement changes; provider updates published through October 2025. Policy continues to define cryoablation as medically necessary for specified lung cancer indications and not medically necessary for breast, pancreas, and bone tumors.