CurrentCapital BluecrossPolicy MP 1.088

Cryoablation of tumors located in the kidney, lung, breast, pancreas, or bone

This policy defines medical necessity criteria, limitations, and investigational indications for cryosurgical ablation (cryoablation) of localized tumors in adults involving the kidney, lung, breast, pancreas, or bone for Capital BlueCross products.

Policy Summary

PayerCapital Bluecross

PolicyCryoablation of tumors located in the kidney, lung, breast, pancreas, or bone

Policy CodePolicy MP 1.088

Change TypeNo material changes

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization and verify member benefits before scheduling cryoablation per product-specific rules.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4 cmmax renal tumor size

18+adult minimum age

>=400renal case series

changedbone indication change

0970T/0971Tcodes added

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria for Cryoablation

Prior Authorization

Provider Actions / Billing Rules

Benefit verification and prior authorization: Providers must verify member benefits before scheduling cryoablation. Prior authorization may be required — coverage is determined by the member's benefit plan. Requests for investigational indications (e.g., breast, pancreas, certain renal cases) are subject to denial if not supported by the member's benefit language.

Verify member eligibility and benefits, including any product-specific exclusions or limitations prior to services.
Obtain prior authorization when required by the member’s benefit plan; denial risk exists for investigational indications.
Coverage is determined by the terms of the member’s benefit plan — medical necessity decisions in this policy do not guarantee coverage under all products.

Coding and Code References

Device/product code referencesmixed

GEH	FDA product code cited for cryoablation devices

Procedure Codes listedCPT

0581T
0970T
0971T
19105
20983
32994
50250
50542
50593
C2618

Diagnosis codes listedICD-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

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inv-12: Maximum tumor size for renal cryoablation —

Maximum renal tumor sizeTumor diameter ≤ 4 cm

ContextApplies when treating localized renal cell carcinoma with cryosurgical ablation

Policy conditionMedical necessity requires either patient is not a surgical candidate or preservation of kidney function is necessary (e.g., solitary kidney or GFR <60 mL/min/1.73 m2)

inv-13: Policy history effective dates and coding changes (e.g., 0581T, admin updates)

Temporary CPT addedCode 0581T added effective 01/01/2020

Other coding updatesAdditional procedure codes listed in policy include 0970T, 0971T and CPT codes 19105, 20983, 32994, 50250, 50542, 50593, C2618

Administrative updatesPolicy administrative updates and references to coding changes through 06/12/2025

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior authorization and product-specific applicability

Prior authorization is required according to product-specific rules; this policy applies only to certain Capital Blue Cross programs and products and coverage may vary by benefit.

Policy applicability is limited to certain Capital Blue Cross programs and products
Benefit variations in Section VI may affect prior authorization requirements

Prior Authorization

Benefit verification / prior authorization required per member contract

Coverage and reimbursement depend on the member's benefit terms; the presence of codes in the policy does not guarantee coverage—prior authorization or benefit verification is required per the member contract.

Identification of a code does not denote coverage (coverage determined by member benefit information)
Contact Provider Services or Member Services for benefit questions

Background and Rationale

Cryosurgical ablation (cryoablation or cryosurgery) destroys target tissue by freezing using percutaneously, laparoscopically, or open‑placed probes under imaging guidance. The technique may be used as an alternative to surgery when patients are poor surgical candidates or when organ preservation is a priority, and procedural approaches vary by tumor site and clinical context.

Definitions

inv-23: cryoablation (cryosurgery) definition

DefinitionCryosurgical ablation (cryoablation) involves freezing target tissues by inserting a coolant-carrying probe into the tumor

TechniquesMay be performed as an open surgical technique, laparoscopically, or percutaneously under imaging guidance

PurposeUsed to destroy tumor tissue by freezing; investigated or used as an alternative to surgery in poor surgical candidates or when organ preservation is desired

inv-24: adult (age 18 years and older)

Age requirementAdults only: age 18 years and older

Pediatric scopePolicy does not address pediatric populations

Policy Summary

PayerCapital Bluecross

PolicyCryoablation of tumors located in the kidney, lung, breast, pancreas, or bone

Policy CodePolicy MP 1.088

Change TypeNo material changes

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization and verify member benefits before scheduling cryoablation per product-specific rules.

SourceLink

On This Page

Step Therapy

Step therapy not specified

Step therapy requirements are not specified in this portion of the policy.

Note

Provider action — verify policy criteria and contact services for questions

Providers should follow the policy criteria and confirm medical necessity when submitting requests; contact Provider Services or Member Services for questions about applicability.

Ensure requested indication meets policy medical necessity criteria before submission
Use Provider Services or Member Services for coverage or policy applicability questions

Documentation Required

Required clinical documentation

Document the patient's age (policy applies to adults ≥18 years), tumor size when relevant (e.g., renal tumor ≤4 cm when claiming medical necessity), and the clinical rationale such as why the patient is not a surgical candidate or why organ preservation is necessary.

Patient age — must be 18 years or older
Tumor size — e.g., renal tumor ≤4 cm to meet renal criteria
Clinical rationale — non‑surgical candidacy or need for kidney preservation (e.g., solitary kidney or GFR <60 mL/min/1.73 m2)

Billing Rule

Coverage and claims processing depend on member benefits and medical necessity

Final claim adjudication depends on the member's benefit program, eligibility on the date of service, and that services are medically necessary and appropriate; this policy is not a guarantee of payment.

Payment subject to member benefit terms and eligibility on date of service
Claims must meet medical necessity and appropriateness criteria

Note

Code listing does not guarantee coverage — verify member benefits

Coverage is determined by the member's benefit program and eligibility; identification of a code in the coding section does not denote coverage.

Coding lists are not a guarantee of coverage
Verify coverage via member benefit information

Documentation implication

Patient age must be documented to demonstrate adult eligibility for the policy

inv-25: Definitions

Definitions presentNo definitions provided in this section of the document (V. DEFINITIONS: NA)

ImplicationStandard clinical terms (e.g., cryoablation, adult) are referenced elsewhere rather than defined here

Action for reviewersRefer to clinical context/background and other sections for operational definitions when needed