CurrentCareSource GeorgiaPolicy Tumors-MP-MM-1351

Radiofrequency and Microwave Ablation of Tumors

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Defines medical necessity, coverage criteria, and limitations for radiofrequency (RFA) and microwave (MWA) thermal ablation of tumors for CareSource Georgia members; applies to clinical indications including liver, lung, kidney, thyroid, bone, soft tissue, and select benign conditions. Affects providers requesting authorization or billing for these procedures under this payer policy.

Policy Summary

PayerCareSource Georgia

PolicyRadiofrequency and Microwave Ablation of Tumors

Policy CodePolicy Tumors-MP-MM-1351

Change TypeAdded and revised indications (material changes)

Effective DateMay 1, 2026

Last ReviewSep 27, 2025

Next Review DateMay 1, 2026

Key ActionObtain prior authorization and document indication-specific criteria (tumor size, resectability/surgical candidacy, lesion location, number of nodules, liver function, and absence/presence of extrahepatic disease).

SourceLink

POLICY UPDATE CHANGES

Added indications for Barrett esophagus and thyroid nodules.

Expanded background and added renal MWA indications.

≤5 cmLiver max diameter

≤3 cmNodule / lung size limit

≤4 cmRenal T1 threshold

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CurrentCareSource GeorgiaPolicy Tumors-MP-MM-1351

Radiofrequency and Microwave Ablation of Tumors

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Policy Summary

PayerCareSource Georgia

PolicyRadiofrequency and Microwave Ablation of Tumors

Policy CodePolicy Tumors-MP-MM-1351

Change TypeAdded and revised indications (material changes)

Effective DateMay 1, 2026

Last ReviewSep 27, 2025

Next Review DateMay 1, 2026

SourceLink

POLICY UPDATE CHANGES

Added indications for Barrett esophagus and thyroid nodules.

Expanded background and added renal MWA indications.

≤5 cmLiver max diameter

≤3 cmNodule / lung size limit

≤4 cmRenal T1 threshold

State marketplaces listedScope

Medical Necessity and Coverage Criteria

Microwave ablation — medically necessary indications

Covered when ONE of the following microwave ablation indications is met:

MWA Hepatic: Member has primary or metastatic hepatic (liver) tumor and ALL: (1) the tumor is unresectable due to location of lesion(s) OR the member has comorbid condition(s) that are contraindicative to surgery; (2) the tumor is ≤ 5 cm in size OR there are no more than 3 nodules, all of which are ≤ 3 cm in size; (3) microwave ablation may be used alone or in conjunction with open or minimally invasive resection of other liver tumors, with curative resection of all disease the stated goal of therapy.≤ 5 cm or ≤ 3 nodules ≤ 3 cm

MWA using an FDA‑approved device.

MWA Lung: Member has primary or metastatic lung tumor and ALL: (1) the tumor is unresectable due to location of lesion(s) OR the member has comorbid condition(s) that are contraindicative to surgery; (2) single tumor is ≤ 3 cm in size.single tumor ≤ 3 cm

MWA using an FDA‑approved device.

MWA Renal: Member has T1 renal cell carcinoma and ONE of the following: (1) renal mass is ≤ 4 cm in size and the member is not eligible for surgery or declines surgery; (2) renal mass is > 4 cm but ≤ 7 cm and the member is not eligible for surgery.≤ 4 cm (or > 4 to ≤ 7 cm if not surgical candidate)

Renal MWA indication.

Radiofrequency ablation — medically necessary indications

Radiofrequency ablation is considered medically necessary for ANY of the following indications (with specific subcriteria where noted):

Barrett esophagus with dysplasia: RFA for Barrett esophagus with dysplasia is medically necessary.

Bone metastases: RFA for painful or symptomatic bone metastases is medically necessary.

Hepatocellular carcinoma (HCC): RFA for hepatocellular carcinoma when ALL: (1) Child‑Pugh class A or B liver function (score of 9 or less); (2) surgical evaluation indicates at least one of: candidate for surgical resection following RFA, candidate for transplant following bridge therapy by RFA, not a surgical candidate (or elects against surgery), or not a transplant candidate; (3) tumor has all of: location amenable to percutaneous/minimally invasive/open ablation, margins accessible to ablation, not in close proximity to critical structures (eg, major vessels, major bile ducts, diaphragm, other intra‑abdominal organs), and single tumor ≤ 5 cm in diameter OR no more than 3 tumors each ≤ 3 cm in diameter; (4) no portal hypertension.Child‑Pugh A/B (≤9); single tumor ≤ 5 cm or ≤ 3 tumors ≤ 3 cm

MCG updates take precedence.

Microwave ablation (MWA) is subject to specific coverage limits. MWA is covered only when performed with an FDA‑approved device and when one of the authorized indications is met — for example: primary or metastatic hepatic tumors meeting the size and resectability criteria (tumor ≤ 5 cm or up to 3 nodules ≤ 3 cm and unresectable or patient not a surgical candidate), primary or metastatic lung tumors when a single tumor is ≤ 3 cm and unresectable or surgery is contraindicated, and T1 renal cell carcinoma under the stated size and surgical‑eligibility conditions (≤ 4 cm, or >4 cm and ≤ 7 cm when the member is not eligible for surgery). Procedures outside these specified indications or not using an FDA‑approved device do not meet coverage criteria.

Microwave ablation for any indication not explicitly listed in this policy is considered not medically necessary/experimental and investigational. This includes MWA for tumor types or tumor sizes outside the documented indications (for example, tumors larger than the size thresholds in the hepatic, pulmonary, or renal criteria). Such requests lack sufficient clinical evidence of efficacy compared to other treatment modalities and will be denied as investigational.

Tumor Size Thresholds and Coding-relevant Limits

Tumor size thresholds — key limits

Liver (primary or metastatic)Single tumor ≤5 cm OR up to 3 nodules, each ≤3 cm

Lung (primary or metastatic)Single tumor ≤3 cm

Renal (T1 renal cell carcinoma)Renal mass ≤4 cm (or >4 cm and ≤7 cm if member is not eligible for surgery)

Prior Authorization, Documentation, and Provider Requirements

Prior Authorization

Prior authorization required — demonstrate indication-specific criteria

Prior authorization is required; providers must document that the requested microwave or radiofrequency ablation meets the applicable, indication‑specific criteria (for example: tumor type, tumor size thresholds, number of nodules, surgical candidacy/resectability, lesion location and proximity to critical structures) before approval will be granted.

Demonstrate indication-specific criteria (e.g., hepatic tumor ≤5 cm or ≤3 nodules ≤3 cm; lung single tumor ≤3 cm; T1 renal mass ≤4 cm or >4–≤7 cm when surgery not possible).
Show that the tumor is unresectable due to location or the member has comorbid conditions contraindicative to surgery when required by the indication.
For RFA HCC, show Child‑Pugh class A or B (score ≤9) and absence of portal hypertension when applicable.

Step Therapy

Step therapy — no mandated steps; use multidisciplinary selection

No formal step‑therapy sequence is specified in this policy; clinical selection between ablation and other modalities should be based on tumor type, size, location, surgical candidacy, and multidisciplinary/surgical evaluation.

Clinical Background and Scope

Radiofrequency ablation (RFA) and microwave ablation (MWA) are thermal tumor‑ablation techniques that produce localized tissue necrosis by applying heat to targeted lesions. RFA delivers radiofrequency energy to generate heat, while MWA uses high‑frequency microwaves to agitate water molecules and rapidly convert energy to heat, both resulting in thermal coagulative necrosis of the tumor. These modalities are used as treatment options for primary or metastatic tumors in organs such as liver, lung, and kidney when surgical resection is not feasible, as a bridge to transplant or resection, or for palliative control of symptomatic lesions; appropriateness depends on tumor type, size, number, location, and the member’s surgical candidacy.

Key Definitions

Microwave Ablation (MWA)

DefinitionDelivery of high-frequency microwave energy to rapidly agitate water molecules in target tissue, converting energy to heat that causes tissue necrosis.

Typical useThermal ablation option for primary or metastatic tumors in liver, lung, kidney and select other sites when surgery is not feasible or declined.

Device requirementMWA for tumor treatment is considered medically necessary only when performed using an FDA-approved device per policy criteria.

Radiofrequency Ablation (RFA)

DefinitionDelivery of radio waves to generate heat and induce tissue destruction in the targeted area.

Clinical roleRFA is used for indications including HCC, liver metastases, NSCLC (stage I), kidney T1 lesions, bone metastases, osteoid osteoma, thyroid and soft tissue applications as specified in policy.

Policy Changes and Revision History

2026-02-11revisionLatest

Review: added indications for Barrett esophagus and thyroid nodules; updated references; approved at Committee.

2025-06-18revision

Review: expanded background and added renal microwave ablation (MWA) indications; approved at Committee.

2024-08-28review

Policy Summary

PayerCareSource Georgia

PolicyRadiofrequency and Microwave Ablation of Tumors

Policy CodePolicy Tumors-MP-MM-1351

Change TypeAdded and revised indications (material changes)

Effective DateMay 1, 2026

Last ReviewSep 27, 2025

Next Review DateMay 1, 2026

SourceLink

On This Page

Kidney tumor: RFA for kidney tumor when ALL: (1) clinical stage T1 renal lesion; (2) patient is not candidate for or elects against active surveillance; (3) patient is not a surgical candidate (or elects against surgery); (4) tumor is not a renal angiomyolipoma.T1 lesion

Colorectal liver metastases: RFA for liver metastases from colorectal carcinoma when ALL: (1) patient is not an ideal surgical candidate (or elects against surgery); (2) tumor location amenable to percutaneous or surgical ablation, margins accessible, and not in close proximity to critical structures (eg, major vessels, major bile ducts, diaphragm, other intra‑abdominal organs); (3) single tumor ≤ 5 cm in diameter OR no more than 3 tumors each ≤ 3 cm in diameter; (4) no extrahepatic disease.≤ 5 cm or ≤ 3 tumors ≤ 3 cm; no extrahepatic disease

NSCLC (stage I): RFA for non‑small cell lung cancer when ALL: (1) patient is not a surgical candidate (or elects against surgery); (2) tumor is less than 3 cm in diameter, node negative (stage I), and not in close proximity to major pulmonary vessels or esophagus.< 3 cm; node negative

Osteoid osteoma: RFA for osteoid osteoma is medically necessary.

Soft tissue sarcoma: RFA for soft tissue sarcoma when at least ONE of the following: (1) gastrointestinal stromal tumor (GIST) with limited progressive disease (appearance of new lesion or increase in tumor size); (2) soft tissue sarcoma of extremity, superficial trunk, or head/neck with synchronous stage IV disease and need for treatment of tumor bulk limited to a single organ amenable to local therapy or for palliation of disseminated metastases.

Thyroid cancer: RFA for thyroid cancer when at least ONE of the following: (1) differentiated thyroid carcinoma (eg, follicular, papillary) with distant metastasis or persistent disease not amenable to radioactive iodine, or recurrent disease following locoregional treatment; (2) medullary carcinoma with need for palliative treatment of symptomatic metastases or progressive disease, or asymptomatic disease with disease metastasis, persistent disease following locoregional treatment, or recurrent disease following locoregional treatment.

Thyroid nodules: RFA for thyroid nodules when ALL: (1) compressive symptoms from nodules (eg, cough, dysphagia, foreign body sensation, pain, voice changes); (2) patient is not a surgical candidate (or elects against surgery).

Added indication.

Uterine leiomyomas: RFA for uterine leiomyomas when ALL: (1) laparoscopic ultrasound‑guided procedure planned; (2) leiomyomas documented by imaging study (eg, ultrasound or hysteroscopy); (3) patient desires uterine conservation or is not a surgical candidate; (4) patient is premenopausal; (5) persistent symptoms ≥ 3 months directly attributable to leiomyomas, with at least one of: abnormal uterine bleeding unresponsive to conservative management, bowel dysfunction, dyspareunia, infertility, iron deficiency anemia, pelvic pain or pressure, or urinary dysfunction; (6) testing has ruled out other potential causes of symptoms.persistent symptoms ≥ 3 months

Selection of ablation vs. surgery, radiotherapy or other local/systemic therapies must be informed by clinical factors and multidisciplinary discussion.
Policy contains no mandated prior non‑ablative treatment steps before authorization.

Documentation Required

Required clinical documentation to support indication and thresholds

Clinical documentation submitted for authorization must explicitly support the indication and its numeric thresholds and clinical constraints.

Tumor size(s) and number of nodules (e.g., ≤5 cm single hepatic tumor or ≤3 nodules each ≤3 cm; lung <3 cm; renal T1 ≤4 cm or specified >4–≤7 cm scenarios).
Evidence of resectability assessment or documentation that the member is not a surgical candidate or elects against surgery.
Lesion location and proximity to critical structures (major vessels, bile ducts, diaphragm, pulmonary vessels, esophagus) and margins accessible to ablation.
Relevant liver function (e.g., Child‑Pugh class A/B with score ≤9 for HCC) and presence/absence of portal hypertension or extrahepatic disease when required by the indication.

Denial Risk

Experimental/investigational exclusions — out‑of‑criteria procedures will be denied

Procedures performed for tumor types, tumor sizes, or clinical scenarios not listed as medically necessary in this policy (including MWA for other tumor types or tumors larger than specified thresholds) are considered experimental/investigational and will be denied.

MWA is not covered for any indication other than those listed; MWA for other tumor types is considered experimental/investigational due to lack of evidence.
MWA for tumors larger than the stated size limits is considered experimental/investigational and will be denied.

Selection considerationsAppropriateness depends on tumor size, number, location, patient surgical candidacy, and proximity to critical structures.

Tumor Ablation — definition and context

DefinitionDirect application of energy to eradicate or destroy focal tumors; method chosen based on lesion characteristics and required risk mitigation.

MethodsIncludes thermal techniques such as microwave ablation (MWA) and radiofrequency ablation (RFA) which induce thermal necrosis of targeted tissue.

Risk mitigationConsider lesion location, margins, proximity to critical structures, and surgical/transplant candidacy when determining suitability and technique.

Annual review: updated references; approved at Committee Review.

2023-09-27revision

Policy revised (date noted in revision history).

2022-10-12issued

Policy originally issued.