CurrentPremera Blue Cross of WashingtonPolicy 7.01.92

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

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Coverage criteria for cryosurgical ablation of tumors in the kidney, lung, breast, pancreas, or bone, including medically necessary and investigational indications; pediatric indications are not addressed.

Policy Summary

PayerPremera Blue Cross of Washington

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

Policy CodePolicy 7.01.92

Change TypeAdministrative clarificationno material clinical or coverage change

Effective DateOct 1, 2026

Last ReviewSep 7, 2026

Next Review DateNot specified

Key ActionDocument that the applicable medical-necessity criteria are met in the submitted medical records.

SourceLink

POLICY UPDATE CHANGES

The policy was reformatted for clarity and includes a stand-alone policy statement for breast indications, with intent otherwise unchanged.

The policy history states that prior annual reviews updated the literature and guidelines while leaving policy statements unchanged.

Historical coding updates added CPT codes 0581T and 20983 and separately documented changes involving CPT code 19105.

Cryosurgical ablation for benign breast fibroadenomas was changed historically from medically necessary to investigational.

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CurrentPremera Blue Cross of WashingtonPolicy 7.01.92

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

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Sign up for premerabluecrossofwashington Policy 7.01.92 alerts

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Policy Summary

PayerPremera Blue Cross of Washington

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

Policy CodePolicy 7.01.92

Change TypeAdministrative clarificationno material clinical or coverage change

Effective DateOct 1, 2026

Last ReviewSep 7, 2026

Next Review DateNot specified

Key ActionDocument that the applicable medical-necessity criteria are met in the submitted medical records.

SourceLink

POLICY UPDATE CHANGES

The policy was reformatted for clarity and includes a stand-alone policy statement for breast indications, with intent otherwise unchanged.

The policy history states that prior annual reviews updated the literature and guidelines while leaving policy statements unchanged.

Historical coding updates added CPT codes 0581T and 20983 and separately documented changes involving CPT code 19105.

Cryosurgical ablation for benign breast fibroadenomas was changed historically from medically necessary to investigational.

Medical Necessity and Investigational Uses

Localized renal cell carcinoma

Cryosurgical ablation may be considered medically necessary for localized renal cell carcinoma when either criterion is met.

Renal cryoablation medical necessity

Kidney preservation required: Preservation of kidney function is necessary and standard surgical resection of renal tissue is likely to substantially worsen kidney function.
Kidney preservation is necessary because the individual has one kidney or has renal insufficiency defined by GFR <60 mL/min/m².
Not a surgical candidate: The individual is not considered a surgical candidate.

Lung cancer

Cryosurgical ablation may be considered medically necessary for lung cancer when either criterion is met.

Lung cryoablation medical necessity

Early-stage NSCLC with poor surgical candidacy: The individual has early-stage non-small cell lung cancer and is a poor surgical candidate.
Palliative treatment of central airway obstruction: The individual requires palliation for a central airway-obstructing lesion.

Investigational or unproven uses

Cryosurgical ablation is considered investigational for the following conditions.

Investigational indications

Breast tumors: Benign or malignant tumors of the breast.
Bone tumors: Bone cancer or bone metastases.
Other lung tumors: Lung tumors or lung metastases other than the defined medically necessary indications.
Pancreatic cancers.
Surgical candidates with renal cell carcinoma:

Localized renal masses

AUA guideline recommendations for localized renal masses suspicious for renal cell carcinoma.

AUA thermal ablation recommendation: Thermal ablation may be considered as an alternate approach for management of cT1a renal masses smaller than 3 cm.cT1a and <3 cm

A percutaneous technique is preferred over a surgical approach whenever feasible to minimize morbidity.

Thermal ablation modality: For individuals who elect thermal ablation, either radiofrequency ablation or cryoablation may be offered.

Conditional recommendation; level of evidence C.

Counseling before thermal ablation: Counseling should address the increased likelihood of tumor persistence or local recurrence after primary thermal ablation compared with surgical excision and the possibility of repeat ablation if further intervention is needed.

Strong recommendation; level of evidence B.

NCCN kidney cancer criteria

NCCN kidney cancer guidance.

Percutaneous ablation for renal lesions: Percutaneous ablation, including cryosurgery, radiofrequency ablation, or microwave ablation, is an option for clinical stage T1 renal lesions and is suitable for renal masses 3 cm or smaller.Clinical stage T1; ≤3 cm

Biopsy is recommended before or at the time of ablation.

Selected T1b renal masses: Percutaneous ablation may be an option for clinical T1b masses in selected patients who are not eligible for surgery.Clinical T1b; not eligible for surgery

Retreatment may be required to achieve local oncologic outcomes comparable to conventional surgery.

NSCLC image-guided thermal ablation

NCCN NSCLC guidance.

High-risk or medically inoperable NSCLC: Image-guided thermal ablation may be considered for patients whose tumors are generally surgically resectable but who are rendered medically inoperable because of comorbidities.High risk or medically inoperable

Multidisciplinary evaluation is recommended when IGTA is considered for high-risk or borderline-operable individuals.

NSCLC lesion size and setting: IGTA is an option for NSCLC lesions smaller than 3 cm and may be used in selected stage IA NSCLC, patients with multiple lung cancers, or locoregional recurrence of symptomatic local thoracic disease.<3 cm; selected stage IA, multiple lung cancers, or symptomatic locoregional recurrence

Ablation of lesions larger than 3 cm may have higher local recurrence and complication rates.

Pain from bone metastases

NCCN adult cancer pain guidance.

Ablation for cancer pain: Ablation techniques may be helpful for pain management in individuals with bone metastases who receive inadequate relief from pharmacological therapy.Inadequate relief from pharmacological therapy

The guideline does not specifically address cryoablation for bone metastasis pain.

This policy does not address pediatric indications.

Coding and Clinical Thresholds

CPT CodesCPT

0581T	Ablation, malignant breast tumor(s), percutaneous, cryotherapy, including imaging guidance when performed, unilateral.
19105	Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma.
20983	Ablation therapy for reduction or eradication of 1 or more bone tumors (e.g., metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; cryoablation.
32994	Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, including imaging guidance when performed, unilateral; cryoablation.
50250	Ablation, open, one or more renal mass lesion(s), cryosurgical, including intraoperative ultrasound guidance and monitoring, if performed.
50593	Ablation, renal tumor(s), unilateral, percutaneous, cryotherapy

FDA Product Codemixed

GEH	FDA product code for cryoablation devices

Historical coding updatesCPT

0581T	CPT code added in a historical coding update; the full descriptor is not provided in this window.
20983	CPT code added in a historical coding update; the full descriptor is not provided in this window.
19105	CPT code referenced in a historical coding update; the full descriptor is not provided in this window.

Renal insufficiency

CriterionRenal insufficiency is defined as a GFR of less than 60 mL/min/m².

Clinical contextThis threshold applies when kidney preservation is necessary and standard surgical resection is likely to substantially worsen kidney function.

DocumentationMedical records should document the GFR and the anticipated impact of standard surgery on kidney function.

cT1a renal mass

Tumor categorycT1a renal mass.

Size thresholdSmaller than 3 cm.

Documentation and Operational Requirements

Documentation Required

Medical-Necessity Documentation

Submit medical records demonstrating that the applicable medical-necessity criteria are met for the requested cryosurgical ablation.

For localized renal cell carcinoma, document the need to preserve kidney function because the individual has one kidney; or has renal insufficiency (GFR <60 mL/min/m²) and standard surgical resection is likely to substantially worsen kidney function; or is not considered a surgical candidate.
For lung cancer, document that the individual has early-stage non-small cell lung cancer and is a poor surgical candidate, or requires palliation for a central airway-obstructing lesion.

Note

Renal Lesion Biopsy

For renal lesions, follow the NCCN recommendation to obtain a biopsy before or at the time of percutaneous ablation.

NCCN Kidney Cancer guideline v2.2026 recommends biopsy of renal lesions prior to or at the time of ablation.

Cryoablation Overview

Cryosurgical ablation, or cryoablation, uses extreme cold delivered through a coolant-carrying probe placed into the target tumor to freeze and destroy part or all of the tissue. The procedure may be performed as an open surgical technique or as a closed procedure under laparoscopic or ultrasound guidance. After treatment, the frozen tissue thaws and is absorbed by the body.

Policy Terms and Abbreviations

Cryosurgical ablation / cryoablation

ProcedureCryosurgical ablation, also called cryosurgery or cryoablation.

MechanismExtreme cold is delivered through a coolant-carrying probe to freeze and destroy part or all of a tumor; the frozen tissue subsequently thaws and is absorbed by the body.

TechniqueThe procedure may be performed as an open surgical technique or as a closed procedure under laparoscopic or ultrasound guidance.

Central airway-obstructing lesion

DefinitionA lung lesion that obstructs a central airway.

Policy useCryoablation may be used for symptom palliation when the individual requires palliation for the lesion.