CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Microwave Ablation (MWA) for Tumors — Coverage Criteria

Policy governing medical necessity, coverage, and prior authorization requirements for microwave ablation (MWA) of primary and metastatic tumors for Blue Cross Blue Shield - Rhode Island members (BlueCHiP for Medicare and Commercial products).

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMicrowave Ablation (MWA) for Tumors — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb 1, 2020

Next Review DateN/A

Key ActionObtain prior authorization for BlueCHiP for Medicare members and verify member benefits for Commercial products.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

single <5 cm or up to 3 <3 cmLiver MWA size/number criteria

single <3 cmLung MWA size criterion

PA requiredBlueCHiP for Medicare

other sites / multiple tumorsNot covered

30+Reference citations

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Coverage Criteria

Medically necessary indications (liver and lung)

Covered when ALL of the following are met

Liver MWA criteria: Tumor is unresectable due to lesion location and/or comorbid conditions AND (a single tumor <5 cm OR up to 3 nodules <3 cm each)

Applies to primary or metastatic hepatic tumors

Lung MWA criteria: Tumor is unresectable due to lesion location and/or comorbid conditions AND single tumor <3 cm

Applies to primary or metastatic lung tumors

Microwave ablation (MWA) of primary or metastatic tumors other than liver or lung is considered not covered for BlueCHiP for Medicare and not medically necessary for Commercial products. The policy states the evidence is insufficient to determine the effects of MWA on health outcomes for tumors at anatomic sites other than the liver or lung, and coverage is therefore not provided for those indications.

Microwave ablation of more than a single primary or metastatic tumor in the lung is considered not covered for BlueCHiP for Medicare and not medically necessary for Commercial products. The policy identifies treatment of multiple lung tumors with MWA as lacking sufficient evidence of clinical benefit and therefore excluded from coverage.

Coding and Tumor Size Criteria

Covered / reporting codesCPT | HCPCSCovered

C9751

Bronchoscopy, rigid or flexible, transbronchial ablation of lesion(s) by microwave energy, including fluoroscopic guidance, when performed, with computed tomography acquisition(s) and 3-d rendering, computer-assisted, image-guided navigation, and endobronchial ultrasound (EBUS) transtracheal and/or transbronchial sampling and all mediastinal and/or hilar lymph node stations and therapeutic intervention(s) guided

unlisted CPT (anatomic area specific)

Report the unlisted CPT code for the anatomic area specific to microwave tumor ablation

Liver tumor size/number

Eligibility thresholdSingle hepatic tumor <5 cm OR up to 3 hepatic nodules <3 cm each

Clinical context requirementTumor must be unresectable due to lesion location and/or patient comorbid conditions

Applies toPrimary or metastatic hepatic tumors

Lung tumor size

Eligibility thresholdSingle pulmonary tumor <3 cm

Clinical context requirementTumor must be unresectable due to lesion location and/or patient comorbid conditions

Applies to

Provider Actions and Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for BlueCHiP for Medicare members and recommended for Commercial products. Providers should consult member-specific benefits and contact the provider call center to confirm prior authorization requirements for the individual member.

Prior authorization required for BlueCHiP for Medicare; recommended for Commercial products
Providers must verify member-specific prior authorization rules via the provider call center

Note

Benefit Verification

Verify surgery and procedure benefits in the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement before scheduling services. Benefits and eligibility are determined by the subscriber contract and may vary between groups and plans.

Check the member's Benefit Booklet / Evidence of Coverage / Subscriber Agreement for applicable surgery benefits
Benefits may vary by group/contract

Background

Microwave ablation (MWA) is a thermal tumor‑ablation technique that delivers microwave energy via antennae inserted into the lesion to produce rapid localized heating, coagulative necrosis, and local tumor destruction. It may be performed percutaneously, laparoscopically, thoracoscopically, or open under image guidance for local tumor control, palliation, or as a bridge to transplant. Compared with radiofrequency ablation, MWA can provide higher active heating, less susceptibility to heat‑sink effects from adjacent blood flow, and allows simultaneous use of multiple antennas without grounding pads.

Definitions

Microwave Ablation (MWA) — definition

DefinitionA thermal ablation technique using microwave energy delivered via one or more antennas inserted into the tumor to induce localized tissue heating and coagulative necrosis for tumor destruction

MechanismMicrowave energy (commonly 915 MHz or 2.45 GHz) creates rapid heating by causing water molecule rotation, producing thermal coagulation and localized necrosis

Delivery methodsCan be performed percutaneously, laparoscopically, thoracoscopically, or open under image guidance; single or multiple antennas may be used

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMicrowave Ablation (MWA) for Tumors — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb 1, 2020

Next Review DateN/A

Key ActionObtain prior authorization for BlueCHiP for Medicare members and verify member benefits for Commercial products.

SourceLink

On This Page

Primary or metastatic lung tumors

Note

Benefits & Eligibility Verification

Providers must call the provider call center to verify benefits and eligibility for the specific member. Coverage determinations are based on the member's subscriber agreement or employer contract; this policy is informational and not a guarantee of payment.

Call the provider call center for member-specific benefits and eligibility
Coverage is determined by the subscriber agreement / employer contract

Denial Risk

Member Charge and Denial Risk

If services are determined to be not medically necessary or non-covered for the member, the provider may not charge the member unless the member has been informed in advance and agreed in writing to pay. Providers should review participation agreements for applicable billing provisions.

Providers may be financially liable if services are non-covered or not medically necessary
Member may be charged only with advance informed agreement, per participation agreement

Documentation Required

Coding / Documentation Note

There are no specific CPT codes for microwave tumor ablation. Report the appropriate unlisted CPT code for the anatomic area when performing microwave tumor ablation (C9751 referenced for specific bronchoscopic microwave ablation). Use related HCPCS codes only when medical criteria are met and documentation supports the service.

Report unlisted CPT code for the anatomic area when performing microwave tumor ablation
C9751: Bronchoscopy, transbronchial ablation by microwave energy (when applicable)
Related HCPCS codes covered only if medical criteria are met