CurrentCareSourcePolicy N/A

Radiofrequency and Microwave Ablation of Tumors

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This policy governs coverage and medical necessity criteria for radiofrequency ablation (RFA) and microwave ablation (MWA) of tumors for CareSource members in Arkansas PASSE, specifying indications, size limits, and conditions affecting coverage.

Policy Summary

PayerCareSource

PolicyRadiofrequency and Microwave Ablation of Tumors

Policy CodePolicy N/A

Change TypeAdded and revised clinical indications

Effective DateMay 1, 2026

Last ReviewFeb 11, 2026

Next Review DateN/A

Key ActionObtain prior authorization demonstrating the procedure meets listed clinical criteria (tumor type, size, location, and surgical candidacy).

SourceLink

POLICY UPDATE CHANGES

Added Barrett esophagus and thyroid nodule indications for radiofrequency ablation.

Expanded background and added renal MWA indications.

≤5 cmMWA liver tumor size limit for coverage

≤3 cm

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CurrentCareSourcePolicy N/A

Radiofrequency and Microwave Ablation of Tumors

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Sign up for all CareSource policy alerts

Know when CareSource releases new policies or updates existing guidance.

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Policy Summary

PayerCareSource

PolicyRadiofrequency and Microwave Ablation of Tumors

Policy CodePolicy N/A

Change TypeAdded and revised clinical indications

Effective DateMay 1, 2026

Last ReviewFeb 11, 2026

Next Review DateN/A

Key ActionObtain prior authorization demonstrating the procedure meets listed clinical criteria (tumor type, size, location, and surgical candidacy).

SourceLink

POLICY UPDATE CHANGES

Added Barrett esophagus and thyroid nodule indications for radiofrequency ablation.

Expanded background and added renal MWA indications.

≤5 cmMWA liver tumor size limit for coverage

≤3 cm

MWA/RFA lung single tumor size limit

≤4 cmRenal (T1a) size for coverage

≤3Allowed hepatic nodules

ArkansasPolicy jurisdiction

Coverage and Medical Necessity Criteria

Microwave ablation — Covered indications

Covered when ONE of the following organ-specific indications is met:

MWA Hepatic: Member has primary or metastatic hepatic (liver) tumor and ALL the following: (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 as the stated goal of therapy.see node

from policy section I.A

MWA Lung: Member has primary or metastatic lung tumor and ALL the following: (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.see node

from policy section I.B

MWA Renal (T1): 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.see node

from policy section I.C

Radiofrequency ablation — Covered indications

RFA is considered medically necessary for any of the following indications (with stated criteria):

Barrett esophagus with dysplasia: RFA for Barrett esophagus with dysplasia is a covered indication.none

policy section III.A

Bone metastases: RFA may be used for bone metastases.none

policy section III.B

Hepatocellular carcinoma (HCC): ALL of: (1) Child-Pugh class A or B liver function (score of 9 or less); (2) surgical evaluation indicates at least one of: patient is a candidate for surgical resection following RFA, candidate for transplant following bridge therapy by RFA, patient is not a surgical candidate (or elects against surgery), or patient is not a transplant candidate; (3) tumor has all the following: location amenable to percutaneous, minimally invasive or open surgical 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 or smaller in diameter OR no more than 3 tumors, each of which is 3 cm or smaller in diameter; (4) no portal hypertension.

Per Policy Section II, microwave ablation (MWA) is not covered for any indication other than the specific hepatic, lung, and renal indications listed in Section I. The policy explicitly states that MWA for other tumor types or for tumor presentations beyond the stated size/number limits is excluded from coverage. Providers should therefore expect denials for MWA requests that do not match the organ-specific criteria in Section I (liver, lung, renal T1 as specified).

The policy classifies MWA for any other tumor type as experimental and investigational because of insufficient clinical evidence of efficacy. It also specifies that MWA for tumors larger than the size limits stated in Section I is considered experimental and investigational. Requests for MWA outside the listed tumor types or exceeding the stated size thresholds should be considered not medically necessary under this policy.

Size Thresholds and Coding-relevant Limits

Tumor size thresholds — key limits

Liver tumor size limitTumor ≤ 5 cm, or up to 3 nodules all ≤ 3 cm

Lung tumor size limitSingle tumor ≤ 3 cm

Renal (T1) size limitRenal mass ≤ 4 cm for patients not eligible for or who decline surgery; renal mass >4 cm and ≤7 cm if patient is not eligible for surgery

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior authorization recommended

Prior authorization is recommended — obtain authorization showing the planned MWA or RFA meets the policy clinical criteria (tumor type, size, location, and surgical candidacy) before proceeding.

Step Therapy

Step therapy / prior treatments

No formal step-therapy sequence is defined in the policy; however, the criteria require documentation of surgical evaluation and consideration of alternative treatments (e.g., resection or transplant) where noted prior to ablation.

Documentation Required

Required clinical documentation

Definitions

Tumor Ablation — definition

DefinitionDirect application of energy to eradicate or destroy focal tumors.

Method dependent on lesionAblation method is selected based on lesion characteristics and risk mitigation considerations.

PurposeUsed to achieve focal tumor destruction where surgery is not feasible or as adjunct to surgical approaches.

Microwave Ablation (MWA) — definition

DefinitionDelivery of high-frequency microwave energy to rapidly agitate water molecules in the target tissue; energy is converted to heat, causing tissue necrosis.

MechanismMicrowave energy induces rapid tissue heating leading to coagulative necrosis of the targeted lesion.

Background and Clinical Context

Radiofrequency ablation (RFA) and microwave ablation (MWA) are thermal tumor ablation techniques that destroy focal tumors by applying energy to generate heat and induce coagulative necrosis. RFA delivers radiofrequency energy, while MWA delivers high-frequency microwave energy to agitate water molecules in tissue. These modalities are used for select primary and metastatic tumors when operative resection is not feasible or is contraindicated, with coverage tied to organ-specific criteria including tumor type, size, number, location, and surgical candidacy. The policy’s covered indications reflect these clinical constraints and state size/number thresholds (for example, hepatic lesions ≤ 5 cm or ≤ 3 nodules ≤ 3 cm, single lung lesions ≤ 3 cm, and renal T1 lesions generally ≤ 4 cm unless specific exceptions apply).

Policy Summary

PayerCareSource

PolicyRadiofrequency and Microwave Ablation of Tumors

Policy CodePolicy N/A

Change TypeAdded and revised clinical indications

Effective DateMay 1, 2026

Last ReviewFeb 11, 2026

Next Review DateN/A

Key ActionObtain prior authorization demonstrating the procedure meets listed clinical criteria (tumor type, size, location, and surgical candidacy).

SourceLink

On This Page

policy sections III.C and III (surgical evaluation)

Kidney tumor (RFA): ALL of: (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.see node

policy section III.D

Liver metastases from colorectal carcinoma: ALL of: (1) patient is not an ideal surgical candidate (or elects against surgery); (2) tumor has all the following: location amenable to percutaneous or surgical 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 or smaller in diameter OR no more than 3 tumors, each of which is 3 cm or smaller in diameter; (3) no extrahepatic disease.see node

policy section III.E

Lung cancer (NSCLC): ALL of: (1) patient is not a surgical candidate (or elects against surgery); (2) tumor with all the following: less than 3 cm in diameter, node negative (stage I), and not in close proximity to major pulmonary vessels or esophagus.see node

policy section III.F

Osteoid osteoma: RFA for osteoid osteoma is a covered indication.none

policy section III.G

Soft tissue sarcoma with at least ONE of the following: (1) gastrointestinal stromal tumor with limited progressive disease; (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 single organ amenable to local therapy or palliation of disseminated metastases.none

policy section III.H

Thyroid cancer with 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 treatment of locoregional disease; (2) medullary carcinoma with palliative treatment of symptomatic metastases or progressive disease, or asymptomatic patient with disease metastasis, persistent or recurrent disease following locoregional treatment.none

policy section III.I

Thyroid nodules: ALL of: (1) compressive symptoms from nodules (eg, cough, dysphagia, foreign body sensation, pain, voice changes); (2) patient not a surgical candidate (or elects against surgery); (3) laparoscopic ultrasound-guided procedure planned; (4) nodules documented by imaging study or hysteroscopy; (5) testing has ruled out other potential causes of symptoms; (6) other specified criteria as listed in the policy.see node

policy section III.J

Uterine leiomyomas: ALL of: (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 attributed to presence of leiomyomas, as indicated by at least ONE of: abnormal uterine bleeding unresponsive to conservative management, bowel dysfunction, dyspareunia, infertility, iron deficiency anemia, pelvic pain or pressure, urinary dysfunction; (6) testing has ruled out other potential causes of symptoms.see node

policy section III.K

Submit clinical records that confirm tumor histology/type, lesion size(s) and number, assessment of resectability or surgical candidacy, and tumor location relative to critical structures to demonstrate the procedure meets coverage criteria.

Tumor size and number (e.g., liver ≤5 cm or ≤3 nodules ≤3 cm; lung single ≤3 cm; renal T1 ≤4 cm or ≤7 cm if ineligible for surgery).
Documentation of surgical evaluation (candidate for resection, transplant bridge, not a surgical candidate, or elects against surgery).
Imaging or operative reports indicating lesion location and proximity to critical structures (major vessels, bile ducts, diaphragm, pulmonary vessels, esophagus).
Rationale for ablation (curative intent vs palliative).

Denial Risk

Nonconforming indications risk denial

Claims that do not meet the policy’s explicit size, number, anatomic location, or candidacy criteria (for example tumors larger than stated limits, more nodules than allowed, or inappropriate tumor types) are at risk of denial as experimental, investigational, or not covered.

Device requirementPerformed using an FDA‑approved device for microwave ablation as specified in the policy.

Radiofrequency Ablation (RFA) — definition

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

MechanismRadiofrequency energy produces thermal coagulation necrosis in localized tissue via alternating current.

Clinical useApplied for a range of indications including hepatic, renal (T1), lung, bone, and select soft tissue and thyroid conditions per policy criteria.