CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

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

This policy governs medical necessity and coverage for cryosurgical ablation (cryoablation) of miscellaneous solid tumors such as lung, breast, pancreas, and bone for members of Medicare Advantage and Commercial products of Blue Cross Blue Shield - Rhode Island.

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 DateJan 12, 2021

Next Review DateN/A

Key ActionObtain prior authorization for Medicare Advantage members (recommended for Commercial products) before performing pulmonary cryoablation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1Covered CPT code

3Not covered codes

Medicare & CommercialProducts

Required (MA)Prior auth

Coverage Criteria for Cryosurgical Ablation

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inv-01: Covered Indications — Lung Tumors

Cryosurgical ablation of lung tumors may be considered medically necessary when the following criteria are met:

Indications for pulmonary cryoablation: (1) Early-stage non-small-cell lung cancer in an individual who is a poor surgical candidate; OR (2) Palliation for a central airway–obstructing lesion.

Applies to Medicare Advantage Plans and Commercial Products when policy criteria are met.

inv-02: Not Covered / Not Medically Necessary — Breast, Pancreas, Bone, Other

Cryosurgical ablation is not covered / not medically necessary for the following tumor sites due to insufficient evidence:

Excluded tumor sites: Cryosurgical ablation for benign or malignant tumors of the breast, pancreas, or bone, and other solid tumors or metastases outside the liver, prostate, or renal (kidney) tumor sites is not covered / not medically necessary.

Evidence is insufficient to determine effects on health outcomes; see related policies for liver, prostate, or renal tumor–specific guidance.

Cryosurgical ablation for tumors of the breast, pancreas, bone, and other solid tumors or metastases outside of the liver, prostate, or renal tumors is not supported by sufficient evidence to determine its effects on health outcomes. As a result, these indications are listed as not covered / not medically necessary in this policy. See the related policies for site-specific guidance on liver, prostate, or renal tumor management.

Specific procedure codes that correspond to cryoablation in these excluded sites are listed as non-covered and would be denied if submitted for Medicare Advantage Plans and treated as not medically necessary for Commercial Products (see Coding section).

Coverage and payment for any services described in this policy are governed by the member’s subscriber agreement, member certificate, and/or employer agreement; those documents supersede this policy. This policy is provided for informational purposes and is not a guarantee of payment or a substitute for clinical judgment. For member-specific benefits and eligibility, contact the provider call center.

Cryosurgical ablation is not medically necessary as a treatment for benign or malignant tumors of the breast, pancreas, or bone, and for other solid tumors or metastases located outside the liver, prostate, or kidney. The evidence is insufficient to determine effects on health outcomes for these sites, and procedure codes submitted for these indications will be considered non-covered or not medically necessary.

Coding

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 CodesmixedNot 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

Provider Actions, Authorization, and Billing

Prior Authorization

Prior Authorization Required

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

Prior authorization required for Medicare Advantage Plans
Prior authorization recommended for Commercial Products

Note

Check Member Benefit Booklet

Benefits and coverage vary by contract. Refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement to determine whether the procedure is a covered benefit or considered not medically necessary/not covered.

Check the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable benefits and coverage details.

Denial Risk

Not Covered Codes Trigger Denial

The following CPT/HCPCS codes are not covered for Medicare Advantage Plans and are considered not medically necessary for Commercial Products for the listed indications.

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

Denial Risk

Member Financial Responsibility and Denial Risk

Benefits and eligibility are determined by the member's subscriber agreement, member certificate, and/or employer agreement and those documents supersede this policy. For member-specific determinations, contact the provider call center. If services are determined to be not medically necessary or non-covered benefits, the member may be financially responsible unless they have been informed in writing and agreed in advance to self-pay.

Verify eligibility and benefits with the provider call center prior to service.
Non-covered or not medically necessary services may result in member financial liability if not pre-authorized and/or if the member has not provided written informed agreement to self-pay.

Step Therapy

No Step Therapy Specified

This policy does not specify any step therapy requirements. Standard alternative treatments (e.g., surgical resection, radiotherapy, chemotherapy) are discussed in the policy, but no step-therapy or prior-line failure requirements are imposed for cryoablation.

No step therapy specified in the policy.
Review standard-of-care alternatives described in the policy when considering treatment options.

Documentation Required

Provider Operational Note

Provider operational note: for member-specific benefit questions, prior authorization submission issues, or to clarify coverage determinations, contact the BCBSRI provider call center and refer to the member's subscriber or employer agreement.

Contact the BCBSRI provider call center for member-specific determinations and prior authorization assistance.

Background

Cryoablation is a minimally invasive thermal ablation technique that destroys tissue by freezing; it is typically performed by inserting a coolant-carrying probe into the target lesion. The procedure can be performed via an open approach, laparoscopically, or percutaneously and is commonly done under imaging guidance (for example ultrasound, CT, or MRI) to localize the probe and monitor the freeze zone.

Cryoablation may be used with different procedural modalities depending on tumor location and clinical goals, including single-probe or multi-probe freezing cycles and combinations with other palliative or adjunctive surgical interventions as described in the literature. Imaging guidance is integral to safely placing probes and assessing treatment margins and adjacent structures.

Definitions

Cryosurgical ablation (cryoablation) — definition and brief description

TermCryosurgical ablation (cryoablation)

DefinitionFreezing of target tissues by inserting a coolant-carrying probe into the tumor; may be performed as an open surgical technique or as a closed procedure under laparoscopic or ultrasound guidance.

Typical approachesOpen surgical, laparoscopic, or percutaneous (image-guided) probe placement.

Clinical scope (policy)Addresses cryoablation of miscellaneous solid tumors including breast, bone, pancreas, and lung.

Cryoablation / cryotherapy — minimally invasive thermal ablation definition and application contexts

TechniqueMinimally invasive thermal ablation that uses freezing (cryoablation/cryotherapy) to destroy targeted tissue.

DeliveryPerformed percutaneously or under imaging guidance (eg, ultrasound, MRI) for localized tumor treatment.

Applications cited in literatureInvestigated for breast, pancreatic, and bone tumors in multiple clinical studies and reviews.

Evidence notePublished references include systematic reviews, pilot studies, and single-center series; evidence quality and outcomes vary by tumor site.