CurrentEmblemHealthPolicy MG.MM.SU.52d

Radiofrequency Ablation of Tumors

Defines medical necessity, indications, limitations, and coding for radiofrequency ablation of tumors for EmblemHealth members; applies to providers requesting preauthorization or payment review.

Policy Summary

PayerEmblemHealth

PolicyRadiofrequency Ablation of Tumors

Policy CodePolicy MG.MM.SU.52d

Change TypeMaterial content updates (added investigational indications and clarifications)

Effective DateMay 9, 2025

Next Review DateMay 9, 2025

Key ActionSubmit preauthorization with clinical evidence that the member meets the coverage criteria.

SourceLink

POLICY UPDATE CHANGES

Added non-metastatic desmoid tumors to investigational list.

Clarified that RFA is appropriate for progression in a single metastatic site for gastrointestinal stromal tumors but not for multiple metastatic sites.

Added unresectable intra-hepatic cholangiocarcinoma to list of liver tumors covered.

~20+ICD-10 diagnosis codes listed

~10Procedure/CPT codes listed

NumerousCovered tumor types specified

MultipleExplicit exclusions listed

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Coverage Criteria for RFA

Initial Coverage Criteria

Covered when ANY of the following indications apply and supporting clinical documentation is provided:

Covered Indications: Bone pain secondary to cancer as an interventional or palliative pain management strategy

Covered Indications: Distant metastatic lesions of medullary thyroid carcinoma

Covered Indications: Gastro-intestinal stromal tumors with limited progression in a single metastatic site

Covered Indications

NSCLC specifics: Treatment of stage 1A peripheral tumors (defined as < 3 cm)
NSCLC specifics: Symptomatic airway obstruction as a means to improve quality of life

Covered Indications: Osteoid osteoma as a less invasive alternative to surgical resection

Covered Indications: Renal tumors small (< 4 cm in diameter) suspected to be malignant or with malignant potential< 4 cm

Covered Indications: Symptomatic soft tissue sarcoma with disseminated metastases

Covered Indications

Primary liver: Primary malignancy hepatocellular carcinoma (HCC)
Metastatic liver - eligible origins: Metastatic lesions from colorectal carcinoma, neuroendocrine tumors, or ocular melanoma
Cholangiocarcinoma: Unresectable intra-hepatic cholangiocarcinoma for lesions < 3 cm or for lesions 3–5 cm when combined with arterial therapy (e.g., chemoembolization, radioembolization with yttrium-90)< 3 cm or 3–5 cm when combined with arterial therapy

Covered Indications: Uterine sarcoma: resectable isolated metastases as an alternative to surgical resection

Radiofrequency ablation is not considered medically necessary for the following situations (list not exhaustive): benign thyroid nodules; breast tumors; Brunner's gland hyperplasia; chondroblastoma; gallbladder cancer; gastro-intestinal stromal tumors involving multiple metastatic sites; hepatic metastases from non-colonic primary cancers or hepatic metastases > 5 cm; malignant bile duct obstruction; pancreatic cancer; and non-metastatic desmoid tumors.

RFA is considered investigational / not medically necessary for a subset of benign and malignant tumors where evidence of therapeutic benefit is insufficient. This includes the items listed above (benign thyroid nodules; breast tumors; Brunner's gland hyperplasia; chondroblastoma; gallbladder cancer; pancreatic cancer; malignant bile duct obstruction) and specific tumor scenarios such as gastro-intestinal stromal tumors with multiple metastatic sites, hepatic metastases from non-colonic primaries or lesions > 5 cm, and non-metastatic desmoid tumors (the latter was recently added to the investigational list per the revision history). Decisions for indications outside the covered list are reviewed on a case-by-case basis with supporting clinical documentation.

Coding — Procedure and Diagnosis Codes, Tumor Size Thresholds

Procedure/CPT CodesCPT

20982	Ablation therapy for reduction or eradication of 1 or more bone tumors (metastasis), percutaneous, including imaging guidance; radiofrequency
32998	Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s), percutaneous, including imaging guidance, unilateral; radiofrequency
47370	Laparoscopy, surgical, ablation of one or more liver tumor(s); radiofrequency
47380	Ablation, open, of one or more liver tumor(s); radiofrequency
47382	Ablation, one or more liver tumor(s), percutaneous, radiofrequency
50542	Laparoscopy, surgical; ablation of renal mass lesion(s), including intraoperative ultrasound guidance, when specified as radiofrequency ablation
50592	Ablation, 1 or more renal tumor(s), percutaneous, unilateral radiofrequency
53852	Transurethral destruction of prostate tissue; by radiofrequency thermotherapy
53854	Transurethral destruction of prostate tissue; by radiofrequency generated water vapor thermotherapy
77013	CT guidance for and monitoring of parenchymal tissue ablation

1–10 of 12

1/2

ICD-10 Diagnoses (selected examples)ICD-10

C22.8	Malignant neoplasm of liver, primary, unspecified as to type
C22.9	Malignant neoplasm of liver, not specified as primary or secondary
C34.10	Malignant neoplasm of upper lobe, unspecified bronchus or lung
C64.1	Malignant neoplasm of right kidney, except renal pelvis
C79.51	Secondary malignant neoplasm of bone
D49.51	Neoplasm of unspecified behavior of kidney
689.3	Neoplasm related pain (acute) (chronic)

Tumor size thresholds — key diameter limits for covered indications

NSCLC (stage 1A peripheral)Tumors < 3 cm in diameter

Renal tumorsSmall renal tumors < 4 cm in diameter (suspected malignant or with malignant potential)

Liver lesions — solitary/suitable for RFALesions < 3 cm treated with RFA alone

Liver lesions — combined arterial therapyLesions 3–5 cm when combined with arterial therapy (e.g., chemoembolization or radioembolization with Y-90)

Provider Actions, Authorization & Documentation

Prior Authorization

Prior Authorization Required

Preauthorization is required. The treating physician or primary care provider must submit clinical evidence demonstrating that the member meets the policy coverage criteria when requesting preauthorization.

Preauthorization required prior to service
Submit supporting clinical documentation with request

Billing Rule

Provider Action / Billing Highlight

Providers must take action to request authorization and include all relevant clinical information to support medical necessity. Failure to request prior authorization when required may result in claim denial or delayed payment.

Provider must initiate authorization request before performing procedure

Background

Radiofrequency ablation (RFA) is a percutaneous or surgical technique that uses a small needle electrode to deliver high-frequency radio waves into tumor tissue. The applied energy produces localized heating that causes cellular coagulation and necrosis; the resulting necrotic tissue typically scars and may shrink, providing either curative or palliative effect depending on the tumor type and clinical context.

Definitions

Radiofrequency ablation — definition and technique

Basic definitionA technique that uses a small needle electrode placed directly into a tumor to deliver high-frequency radio waves that heat the tumor and cause local necrosis

MechanismHeating causes tumor cell death; necrotic tissue becomes scar tissue and may shrink over time

DeliveryPerformed percutaneously or via open/laparoscopic approaches using a needle electrode under image guidance

Revision History

2025-05-09addedLatest

Added non‑metastatic desmoid tumors to the investigational (not medically necessary) list.

2019-10-05added

Added unresectable intra‑hepatic cholangiocarcinoma to the list of liver tumors covered by RFA.

2018-05-11clarified