CurrentPremera Blue Cross of WashingtonPolicy 7.01.92

Cryoablation of Tumors Located in the Kidney, Lung

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This policy describes when cryosurgical ablation of selected kidney and lung tumors is medically necessary, investigational, or not covered. Pediatric indications are not addressed.

Policy Summary

PayerPremera Blue Cross of Washington

PolicyCryoablation of Tumors Located in the Kidney, Lung

Policy CodePolicy 7.01.92

Change TypeAdministrative clarification

Effective DateOct 1, 2026

Last ReviewSep 7, 2026

Next Review DateN/A

Key ActionSubmit medical records documenting that the applicable medical-necessity criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Covered lung cancer pathways

GFR <60Renal insufficiency threshold

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CurrentPremera Blue Cross of WashingtonPolicy 7.01.92

Cryoablation of Tumors Located in the Kidney, Lung

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Sign up for premerabluecrossofwashington Policy 7.01.92 alerts

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This policy describes when cryosurgical ablation of selected kidney and lung tumors is medically necessary, investigational, or not covered. Pediatric indications are not addressed.

Policy Summary

PayerPremera Blue Cross of Washington

PolicyCryoablation of Tumors Located in the Kidney, Lung

Policy CodePolicy 7.01.92

Change TypeAdministrative clarification

Effective DateOct 1, 2026

Last ReviewSep 7, 2026

Next Review DateN/A

Key ActionSubmit medical records documenting that the applicable medical-necessity criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Covered lung cancer pathways

GFR <60Renal insufficiency threshold

≤3 cmRenal mass ablation size

<3 cmNSCLC ablation size

Medical Necessity and Investigational Indications

Localized Renal Cell Carcinoma

Cryosurgical ablation may be considered medically necessary for localized renal cell carcinoma when either renal-preservation necessity or nonsurgical candidacy is established.

Renal cell carcinoma eligibility

Kidney preservation required
- Reason kidney preservation is necessary: The individual has one kidney, or has renal insufficiency defined as a GFR of less than 60 mL/min/m².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 cancer eligibility

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

Investigational Indications

Cryosurgical ablation is considered investigational for the following indications.

Investigational tumor 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 covered lung indications.
Pancreatic cancers.
Surgical-candidate renal cell carcinoma:

This policy does not address pediatric indications.

Coding and Reference Thresholds

CPTCPT

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 CPT coding updatesCPT

0581T	CPT code added as a coding update; new code effective 1/1/20.
19105	CPT code removed in a coding update and later listed as added in a subsequent annual review.
20983	CPT code added in a coding update.

Renal insufficiency GFR

ThresholdGFR less than 60 mL/min/m²

DefinitionRenal insufficiency is defined by a glomerular filtration rate (GFR) of less than 60 mL/min/m².

Clinical relevanceRenal insufficiency may establish the need to preserve kidney function when standard surgical resection is likely to substantially worsen kidney function.

cT1a renal mass size

Tumor classificationcT1a renal mass

Size thresholdLess than 3 cm

Documentation and Coverage Risk

Documentation Required

Renal Cell Carcinoma Documentation

Submit medical records establishing that cryosurgical ablation for localized renal cell carcinoma meets the applicable medical-necessity pathway. Documentation must show the need to preserve kidney function or that the individual is not a surgical candidate.

Document that the individual has one kidney; or
Document renal insufficiency with a GFR of < 60 mL/min/m² and explain why standard surgical resection is likely to substantially worsen kidney function; or
Document that the individual is not considered a surgical candidate.

Documentation Required

Lung Cancer Documentation

For lung cancer, submit records demonstrating that the requested ablation meets one of the policy’s covered indications.

Document early-stage non-small cell lung cancer and that the individual is a poor surgical candidate; or
Document that the individual requires palliation for a central airway-obstructing lesion.

Clinical Background

Cryosurgical ablation, also called cryoablation, destroys target tissue by freezing it with a coolant-carrying probe placed in or near the tumor. The procedure may be performed as an open surgery or as a closed procedure using laparoscopic or ultrasound guidance. In this policy, cryoablation is used for selected circumstances involving localized renal cell carcinoma and lung cancer; use for several other tumor types is considered investigational because evidence is insufficient to establish improved net health outcomes.

Policy Definitions

Cryosurgical ablation / cryoablation

ProcedureCryosurgical ablation, also called cryosurgery or cryoablation, involves freezing target tissues.

ApplicationThe procedure most often involves inserting a coolant-carrying probe into the tumor.

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

Renal insufficiency

DefinitionRenal insufficiency is defined as a glomerular filtration rate (GFR) of less than 60 mL/min/m².

ThresholdGFR <60 mL/min/m²

Policy relevance

Policy Summary

PayerPremera Blue Cross of Washington

PolicyCryoablation of Tumors Located in the Kidney, Lung

Policy CodePolicy 7.01.92

Change TypeAdministrative clarification

Effective DateOct 1, 2026

Last ReviewSep 7, 2026

Next Review DateN/A

Key ActionSubmit medical records documenting that the applicable medical-necessity criteria are met.

SourceLink

On This Page

Renal cell carcinoma in an individual who is a surgical candidate.

Treatment guidanceThermal ablation may be considered as an alternate approach; a percutaneous technique is preferred when feasible.

Renal mass size suitable for percutaneous ablation

Renal mass threshold3 cm or less

Treatment settingPercutaneous ablation is an option for clinical stage T1 renal lesions.

Included techniquesPercutaneous ablation may include cryosurgery, radiofrequency ablation, or microwave ablation.

NSCLC lesion size for IGTA option

Lesion thresholdLess than 3 cm

Treatment optionImage-guided thermal ablation (IGTA) is an option for management of NSCLC lesions below this size.

Relevant candidatesIGTA may be considered for individuals at high risk who are medically inoperable because of comorbidities.

NSCLC lesion size and risk

Lesion thresholdGreater than 3 cm

Local recurrenceAblation for NSCLC lesions greater than 3 cm may be associated with higher rates of local recurrence.

ComplicationsAblation for NSCLC lesions greater than 3 cm may be associated with higher rates of complications.

Denial Risk

Investigational Indications

Cryosurgical ablation is considered investigational for the following indications and is not covered under the policy’s medical-necessity criteria.

Benign or malignant tumors of the breast
Bone cancer and bone metastases
Lung tumors and lung metastases other than the defined covered indications
Pancreatic cancers
Renal cell carcinomas in individuals who are surgical candidates

Denial Risk

Failure to Meet Medical Necessity Criteria

Coverage may be denied when submitted records do not establish the applicable renal or lung medical-necessity criteria. Requests for investigational indications, including renal cell carcinoma in a surgical candidate, are also subject to denial.

Renal requests require documentation of kidney-preservation need or that the individual is not a surgical candidate.
Lung requests require documentation of early-stage NSCLC with poor surgical candidacy or palliation of a central airway-obstructing lesion.
Indications identified as investigational are not covered as medically necessary under this policy.

This threshold may support kidney-preservation criteria when standard resection is likely to substantially worsen kidney function.

Image-guided thermal ablation (IGTA)

DefinitionImage-guided thermal ablation uses imaging to guide treatment of a target tumor.

Included techniquesRadiofrequency ablation, microwave ablation, and cryoablation.

NSCLC applicationIGTA is an option for management of NSCLC lesions less than 3 cm.

NSCLC

AbbreviationNSCLC

Full termNon-small cell lung cancer.

Policy contextFor selected NSCLC lesions less than 3 cm, image-guided thermal ablation may be an option.