CurrentCapital BluecrossPolicy MP 1.088

Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone

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This policy defines when cryosurgical ablation (cryoablation) is considered medically necessary or investigational for adults with tumors of the kidney, lung, breast, pancreas, or bone for Capital Blue Cross products.

Policy Summary

PayerCapital Bluecross

PolicyCryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone

Policy CodePolicy MP 1.088

Change TypeAdministrative update — no material clinical changes

Effective DateFeb 1, 2026

Last ReviewAug 13, 2025

Next Review Date

Key ActionObtain prior authorization documenting adult patient status, tumor site and size, and clinical rationale aligning with medical necessity criteria.

SourceLink

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentCapital BluecrossPolicy MP 1.088

Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone

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Policy Summary

PayerCapital Bluecross

PolicyCryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone

Policy CodePolicy MP 1.088

Change TypeAdministrative update — no material clinical changes

Effective DateFeb 1, 2026

Last ReviewAug 13, 2025

Next Review Date

Key ActionObtain prior authorization documenting adult patient status, tumor site and size, and clinical rationale aligning with medical necessity criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4 cmmaximum renal tumor size for renal eligibility

18+policy limited to adults

5organ sites covered

NCCN V2.2025compendia for bone metastases

Medical Necessity and Investigational Indications

inv-01: Renal tumor — medically necessary

Covered when ANY one of the following is met:

Renal cryoablation criteria: Cryosurgical ablation may be considered medically necessary to treat localized renal cell carcinoma that is no more than four (4) cm in size when EITHER: (1) preservation of kidney function is necessary (the patient has one kidney or renal insufficiency defined by a glomerular filtration rate of <60 mL/min/m2) AND standard surgical approach is likely to worsen kidney function substantially; OR (2) the patient is not considered a surgical candidate.tumor size ≤4 cm; GFR <60 mL/min/m2

From policy (see POLICY).

inv-02: Lung tumor — medically necessary

Covered when ANY one of the following is met:

Lung cryoablation criteria: Cryosurgical ablation may be considered medically necessary to treat lung cancer when EITHER: (1) the patient has early-stage non-small cell lung cancer and is a poor surgical candidate; OR (2) the patient requires palliation for a central airway-obstructing lesion.early-stage NSCLC or central airway obstruction

Policy and summary of evidence support these uses.

inv-03: Bone tumors/metastases — medically necessary

Covered when ALL of the following are met:

Bone cryoablation criteria: (1) Indication is pain control in individuals with metastatic bone disease confirmed with imaging (e.g., CT or MRI); AND (2) individuals have failed or are poor candidates for standard treatments such as radiation or opioids; AND (3) surgery is not an option; AND (4) the individual has estimated life expectancy sufficient to achieve benefit from the procedure.imaging-confirmed bone metastasis; prior radiation/opioid failure or contraindication

Limits to adults (age ≥18 years) and requires sufficient life expectancy per Policy Guidelines and evidence.

inv-04: Investigational / Not covered

The following indications are considered investigational (insufficient evidence):

Investigational indications: Cryoablation is considered investigational for treatment of: (1) benign or malignant tumors of the breast; (2) benign or malignant tumors of the pancreas; (3) benign or malignant tumors of the lung that do not meet the medically necessary lung criteria above; and (4) renal cell carcinomas in patients who are surgical candidates.N/A

Policy states insufficient evidence to support net health outcome for these indications.

inv-05: Medically Necessary Indications (summary)

Cryosurgical ablation coverage statements present in this portion:

Medically necessary when criteria met: Cryosurgical ablation is considered medically necessary to treat localized renal cell carcinoma, select lung indications (early-stage NSCLC in poor surgical candidates or palliation of central airway-obstructing lesions), and for pain control from bone metastases when the specific criteria are met.See individual site-specific criteria (renal ≤4 cm; bone imaging-confirmed metastasis; lung early-stage NSCLC or central airway obstruction)

Summary of medically necessary indications; full criteria are in the policy.

inv-06: Investigational / Not Covered Indications

Investigational indications (denied/not covered):

Investigational / Not Covered Indications: Cryosurgical ablation is considered investigational and not medically necessary for: benign or malignant tumors of the breast; tumors of the pancreas; lung tumors that do not meet the policy's medically necessary lung criteria; and renal cell carcinomas in patients who are surgical candidates.N/A

Identification of a code does not denote coverage; see policy for details.

inv-07: Coverage stance (summary)

Policy indicates covered status with specific criteria for bone tumors and other organ sites; detailed criteria not present in this section.

Coverage stance summary: The policy covers cryoablation for tumors in the kidney, lung, and bone when specified criteria are met; other sites (breast, pancreas, and most lung lesions not meeting criteria) are investigational. Bone tumor indications were changed from investigational to medically necessary with defined criteria in the policy history.See site-specific criteria for details

Full criteria and ICD-10 additions are in the main policy document and policy history.

This policy applies only to adults. Coverage determinations for cryosurgical ablation under this policy are limited to patients who are 18 years of age or older. Pediatric populations and treatments for patients under 18 years are not addressed by this policy and require separate clinical review or policy guidance.

Cryosurgical ablation is designated investigational for tumors of the breast and pancreas, and for most lung tumors that do not meet the policy's specific medically necessary lung criteria. Requests for cryoablation for these indications are considered to have insufficient evidence to support net health benefit and may be denied.

The policy statement reiterates that it is not applicable to pediatric populations; the policy was updated to add a clarification that it is not applicable to patients under 18 years of age.

Cryosurgical ablation for tumors of the breast and for tumors of the pancreas is considered investigational and not medically necessary because the available evidence is insufficient to demonstrate improved health outcomes compared with alternative treatments.

Use of cryoablation for the investigational indications listed in this policy (including breast tumors, pancreatic tumors, and most lung tumors that do not meet the medically necessary criteria) is not covered. The policy also notes that renal cell carcinomas in patients who are surgical candidates are considered investigational.

Prior to the 09/27/2023 update, earlier versions of the policy included investigational criteria for some bone tumor indications. Those historical investigational details are not included in this excerpt; subsequent updates changed bone indications from investigational to medically necessary with defined criteria.

Procedure and Diagnosis Codes

Regulatory product codemixed

GEH	FDA product code referenced for cryoablation devices

Procedure Codes (explicit list)CPT

0581T
0970T
0971T
19105

Procedure Codes (additional listed)mixed

20983
32994
50250
50542
50593
C2618	listed repeatedly in document in association with several procedure codes

ICD-10 Diagnosis Codes (malignant and benign neoplasms cited)ICD-10

C34.10	Malignant neoplasm of upper lobe, unspecified bronchus or lung.
C34.11	Malignant neoplasm of upper lobe, right bronchus or lung.
C34.12	Malignant neoplasm of upper lobe, left bronchus or lung.
C34.2	Malignant neoplasm of middle lobe, bronchus or lung.
C34.30	Malignant neoplasm of lower lobe, unspecified bronchus or lung.
C34.31	Malignant neoplasm of lower lobe, right bronchus or lung.
C34.32	Malignant neoplasm of lower lobe, left bronchus or lung.
C34.80	Malignant neoplasm of overlapping sites of unspecified bronchus and lung.
C34.81	Malignant neoplasm of overlapping sites of right bronchus and lung.
C34.82	Malignant neoplasm of overlapping sites of left bronchus and lung.

1–10 of 58

1/6

Tracked CPT/Proprietary CodesCPT

0581T	Previously added procedure code (documented as added 01/01/2020)
0970T	New code added 06/10/2025
0971T	New code added 06/10/2025

ICD-10 codes (bone tumors and related)ICD-10

C40.00	ICD-10 code added (example — policy lists multiple C40 and C41 series codes)
C79.51	ICD-10 code listed in policy history additions
D16.00	ICD-10 code listed in policy history additions

inv-20: Maximum renal tumor size — ≤ 4 cm

Maximum renal tumor size≤ 4 cm

Context in policyApplies to localized renal cell carcinoma eligible for cryoablation when tumor is no more than four (4) cm

Denial riskRequests for cryoablation for renal tumors > 4 cm may be denied as investigational

inv-21: Renal insufficiency threshold (GFR) — < 60 mL/min/m2

Renal insufficiency threshold (GFR)GFR < 60 mL/min/m2

Use in renal criteria

Authorization, Documentation, and Denial Triggers

Prior Authorization

Prior authorization must document age, tumor site/size, and clinical rationale

Obtain prior authorization that documents the patient is an adult (age ≥18), specifies tumor site and measured tumor size, and provides clinical justification that aligns with medical necessity criteria (for example: poor surgical candidacy or need to preserve renal function such as one kidney or GFR <60 mL/min/m2).

Document patient age ≥18.
Specify tumor site and measured size (e.g., renal tumor ≤4 cm when applicable).
Provide clinical rationale: poor surgical candidate OR need to preserve renal function (one kidney or GFR <60 mL/min/m2).

Prior Authorization

Procedure codes listed may be subject to prior authorization

Verify whether the procedure codes listed in the policy (e.g., 0581T, 0970T, 0971T, 19105 and additional listed codes) require prior authorization under the member's benefit plan; inclusion of a code in the policy does not guarantee coverage.

Do not assume coverage solely because a code appears in the policy — check member benefit details.

Clinical Background

Cryoablation is a freezing-based technique that destroys target tissue by insertion of a coolant-carrying probe. It can be performed via an open surgical approach, laparoscopically, or percutaneously under image guidance and is used as an alternative to resection or other focal therapies in selected patients.

Key Definitions

inv-36: Cryosurgical ablation (cryoablation) — Definition of the procedure

DefinitionCryosurgical ablation (cryoablation) is a procedure that freezes target tissues, most often by inserting a coolant-carrying probe into the tumor

ApproachesMay be performed as an open surgical technique or as a closed procedure under laparoscopic or ultrasound (image) guidance

PurposeUsed to destroy tumor tissue for local control or palliation when appropriate

inv-37: Renal insufficiency threshold — Defined as GFR <60 mL/min/m2 for qualifying renal cryoablation

Defined thresholdRenal insufficiency defined as glomerular filtration rate (GFR) <60 mL/min/m2

Role in eligibilityGFR <60 mL/min/m2 is used to justify preservation of kidney function as indication for renal cryoablation

Policy Summary

PayerCapital Bluecross

PolicyCryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone

Policy CodePolicy MP 1.088

Change TypeAdministrative update — no material clinical changes

Effective DateFeb 1, 2026

Last ReviewAug 13, 2025

Next Review Date

Key ActionObtain prior authorization documenting adult patient status, tumor site and size, and clinical rationale aligning with medical necessity criteria.

SourceLink

On This Page

One qualifying criterion for renal cryoablation is preservation of kidney function when GFR <60 mL/min/m2 or single kidney

Documentation requirementPrior authorization/documentation should include GFR value to support medical necessity

Confirm prior authorization requirements per plan for each relevant procedure code.

Billing Rule

Verify coding updates (0970T, 0971T, 0581T) and prior-auth requirements

Be aware that certain CPT/procedure codes are tracked in coding updates — including newly added codes 0970T and 0971T and previously added 0581T — and verify prior authorization and billing requirements with the member's plan.

New codes 0970T and 0971T were added 06/10/2025; code 0581T was previously added (01/01/2020).
Verify plan-specific prior authorization and coding/billing instructions prior to service.

Step Therapy

Step therapy: attempt/consider standard bone metastasis treatments first

For bone metastases, ensure cryoablation is only pursued after standard treatments have failed or when the patient is a poor candidate for those treatments (for example, radiation or opioids) as required by the policy.

Document prior radiation and/or opioid therapy failure or contraindication.
Confirm surgery is not an option and estimated life expectancy is sufficient to achieve benefit.

Documentation Required

Required documentation: age, renal tumor size, and rationale for renal indications

Include documentation that supports the patient is an adult (≥18). For renal tumor indications, document tumor size (≤4 cm) and either the need to preserve renal function (one kidney or GFR <60 mL/min/m2) or that the patient is not a surgical candidate.

Record objective tumor measurement (≤4 cm for renal eligibility).
Record GFR if claiming renal insufficiency (<60 mL/min/m2) or documentation of solitary kidney.
Provide surgeon assessment or other documentation supporting non-surgical candidacy when claimed.

Documentation Required

Document medical necessity and verify benefits — code listing ≠ coverage

Provide documentation that the requested procedure meets the policy's medical necessity criteria and verify member benefits/eligibility on the date of service; listing a procedure code in the policy does not substitute for benefit verification.

Supply clinical records that map to the policy's medical necessity criteria for the indication.
Confirm coverage and prior authorization requirements with the member's plan before scheduling.

Documentation Required

Document diagnosis codes consistent with policy ICD-10 listings

Document diagnosis codes consistent with the policy's listed ICD-10 codes for the indicated bone tumor or other listed indications when submitting authorization requests or claims.

Use ICD-10 codes added for bone tumor indications (e.g., C40.*, C41.*, C79.51) when applicable.
Ensure provider notes support the diagnosis codes submitted.

Denial Risk

Denial risk if renal tumor >4 cm or patient is surgical candidate

Requests may be denied if renal tumors exceed 4 cm or if renal cell carcinoma is treated with cryoablation in patients who are surgical candidates — provide documentation to justify deviations from these criteria.

For renal indications, document tumor size ≤4 cm or explicit rationale if larger.
If treating renal cell carcinoma in a patient claimed non-surgical, include surgeon assessment supporting non-surgical candidacy.

Denial Risk

Denial risk for investigational indications: breast, pancreas, many lung tumors

Cryoablation requests for breast or pancreatic tumors, and for lung tumors that do not meet the policy's medically necessary criteria, are considered investigational and may be denied; do not submit prior authorization without strong justification.

Breast and pancreatic tumor indications are listed as investigational — expect denial.
For lung tumors, ensure the case meets early-stage NSCLC poor surgical candidate or central airway palliation criteria before requesting coverage.

Denial Risk

Investigational indications — high denial risk (breast, pancreas, most lung)

Cryosurgical ablation for benign or malignant breast tumors, pancreatic tumors, and most lung tumors (except those meeting the policy's lung criteria) is labeled investigational — submitting these indications carries a high risk of denial.

Do not expect coverage for breast or pancreatic tumor cryoablation per policy.
For lung tumors, confirm they meet the specified medically necessary criteria before proceeding.

Billing Rule

Administrative/coding updates can trigger coding reviews and administrative denials

Administrative and coding updates (including addition/removal of codes) prompt coding reviews; absence of required coding updates or claim-level coding edits may lead to administrative denials — confirm that claims use current, policy-aligned codes.

Maintain up-to-date coding consistent with policy history (e.g., addition of 0581T, 0970T, 0971T).
Check for required claim-level edits and plan-specific administrative rules to avoid administrative denials.

Associated conditionAlso applies when the patient has a single kidney as need to preserve renal function

inv-38: Investigational — Policy label for investigational indications (breast, pancreas, most lung tumor uses)

Policy labelInvestigational — cryosurgical ablation is considered investigational for benign or malignant tumors of the breast and pancreas

Lung exceptionsAlso investigational for lung tumors that do not meet the policy’s medically necessary lung criteria

Renal caveatInvestigational for renal cell carcinomas in patients who are surgical candidates

inv-39: Cryoablation — Percutaneous or image-guided freezing-based ablation technique referenced in guidelines and studies

Technique descriptionPercutaneous or image-guided freezing-based ablation technique using probe insertion and coolant to create an ice ball to destroy tumor tissue

Guidelines/studies referencedReferenced in trials and guidelines related to image-guided percutaneous cryoablation for bone metastases and renal follow-up (ACR, NCCN, UpToDate)

Clinical uses citedUsed for palliation (e.g., painful bone metastases) and local tumor control in select patients