CurrentBluecross IdahoPolicy MP 7.01.75

Cryosurgical Ablation of Primary or Metastatic Liver Tumors

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This policy governs the use of cryosurgical ablation for primary or metastatic liver tumors under Blue Cross of Idaho benefit plans. The policy determines the service to be investigational, subject to the member-specific benefit plan and applicable law.

Policy Summary

PayerBluecross Idaho

PolicyCryosurgical Ablation of Primary or Metastatic Liver Tumors

Policy CodePolicy N/A

Change TypeLiterature review update

Effective DateSeptember 24, 2026

Last ReviewSep 24, 2026

Next Review DateN/A

Key ActionTreat cryosurgical ablation of primary or metastatic liver tumors as investigational because it may be denied under the applicable benefit plan.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

InvestigationalCoverage status

2%Treatment-related mortality

0%-83%Nonfatal complication rate

Jul 15, 2026Literature cutoff

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CurrentBluecross IdahoPolicy MP 7.01.75

Cryosurgical Ablation of Primary or Metastatic Liver Tumors

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Policy Summary

PayerBluecross Idaho

PolicyCryosurgical Ablation of Primary or Metastatic Liver Tumors

Policy CodePolicy N/A

Change TypeLiterature review update

Effective DateSeptember 24, 2026

Last ReviewSep 24, 2026

Next Review DateN/A

Key ActionTreat cryosurgical ablation of primary or metastatic liver tumors as investigational because it may be denied under the applicable benefit plan.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

InvestigationalCoverage status

2%Treatment-related mortality

0%-83%Nonfatal complication rate

Jul 15, 2026Literature cutoff

Coding and Classification

FDA Product Codemixed

GEH	FDA product code

CPTCPT

47371	Laparoscopy, surgical, ablation of 1 or more liver tumor(s); cryosurgical.
47381	Ablation, open, 1 or more liver tumor(s); cryosurgical.
47383	Ablation, 1 or more liver tumor(s), percutaneous, cryoablation.

HCPCSHCPCS

76940

Ultrasound guidance for, and monitoring of, parenchymal tissue ablation.

HCPCS ICD-10-ICD-10Experimental

No code

Investigational for all relevant diagnoses.

ICD-10-CMICD-10

C22.0-	Malignant neoplasm of liver and intrahepatic bile duct code range.
C22.0-C22.9
C78.7	Secondary malignant neoplasm of liver and intrahepatic bile duct

PCSICD-10

0F500ZZ	Surgical, hepatobiliary system and pancreas, destruction, liver, open.
0F503ZZ	Medical & Surgical hepatobiliary system and pancreas destruction liver percutaneous

Coverage and Billing Guidance

Denial Risk

Investigational liver tumor cryoablation

Cryosurgical ablation of either primary or metastatic tumors in the liver is investigational and may be denied under the applicable benefit plan.

Billing Rule

Verify coverage beyond the code listing

Code inclusion does not guarantee member coverage or provider reimbursement. Coverage determinations remain subject to the member-specific benefit plan documentation, the written coverage position in this medical policy, legal requirements, and other applicable policies and guidelines.

Clinical Background

Liver tumors may be primary cancers, including hepatocellular carcinoma arising from hepatocellular tissue and intrahepatic cholangiocarcinoma arising from the biliary ducts, or metastases from nonhepatic cancers such as colorectal and neuroendocrine tumors. Surgical resection with tumor-free margins and liver transplantation have curative potential, but many hepatic tumors are unresectable because of their anatomic location, size, number of lesions, or limited underlying liver reserve.

Terms and Abbreviations

Cryosurgical ablation (CSA)

Treatment typeLocoregional ablative treatment

Cellular effectFreezes tissue, causing intracellular ice formation and disruption of cellular metabolism

Additional mechanismsVascular coagulation with ischemia and apoptosis, plus induction of apoptosis

Hepatocellular carcinoma (HCC)

Cancer typePrimary liver malignancy

Tissue of originHepatocellular tissue

AbbreviationHCC

CSA

AbbreviationCSA

Full termCryosurgical ablation

Also calledCryoablation or cryotherapy

AbbreviationOS

Full termOverall survival

Policy useOutcome measure listed in the policy abbreviations

PFS

AbbreviationPFS

Full termProgression-free survival

Policy useOutcome measure listed in the policy abbreviations

RFA

AbbreviationRFA

Full termRadiofrequency ablation

Treatment categoryAblative therapy listed among locoregional liver tumor treatments

MWA

AbbreviationMWA

Full termMicrowave ablation

Treatment categoryAblative therapy listed among locoregional liver tumor treatments

TACE

AbbreviationTACE

Full termTransarterial chemoembolization

Treatment categoryLocoregional therapy listed for liver tumors

AbbreviationCI

Full termConfidence interval

Policy useStatistical term listed in the policy abbreviations

CSA in unresectable liver metastases

TherapyCryosurgical ablation

PopulationIndividuals with unresectable liver metastases from neuroendocrine tumors

Treatment roleAn alternative to or an improvement on existing therapies

NCT

AbbreviationNCT

Full termNational clinical trial

ApplicationUsed to identify ongoing and unpublished clinical trials in the policy trial table

Policy Summary

PayerBluecross Idaho

PolicyCryosurgical Ablation of Primary or Metastatic Liver Tumors

Policy CodePolicy N/A

Change TypeLiterature review update

Effective DateSeptember 24, 2026

Last ReviewSep 24, 2026

Next Review DateN/A

Key ActionTreat cryosurgical ablation of primary or metastatic liver tumors as investigational because it may be denied under the applicable benefit plan.

SourceLink

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