CurrentPriority Health MedicarePolicy 91649

Histotripsy for Malignant Liver Tumors

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This policy governs coverage of histotripsy, including the Edison Histotripsy System, for malignant liver tumors in Priority Health Medicare members. Coverage is limited to medically necessary treatment meeting the specified tumor size, age, and multidisciplinary-treatment criteria.

Policy Summary

PayerPriority Health Medicare

PolicyHistotripsy for Malignant Liver Tumors

Policy CodePolicy N/A

Change TypeNew policy

Effective Date03/01/2026

Next Review DateN/A

Key ActionDocument multidisciplinary-team review showing that other well-established ablation methods, arterially directed therapies, and radiation therapy were considered and determined not suitable.

SourceLink

POLICY UPDATE CHANGES

This is a new histotripsy policy established as of February 2026.

18+Minimum member age for covered histotripsy

≤ 3 cmMaximum tumor size for covered treatment

9ICD-10 codes supporting medical necessity

3Alternative treatment categories that must be unsuitable

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CurrentPriority Health MedicarePolicy 91649

Histotripsy for Malignant Liver Tumors

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Sign up for priority_health_medicare Policy 91649 alerts

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Policy Summary

PayerPriority Health Medicare

PolicyHistotripsy for Malignant Liver Tumors

Policy CodePolicy N/A

Change TypeNew policy

Effective Date03/01/2026

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

This is a new histotripsy policy established as of February 2026.

18+Minimum member age for covered histotripsy

≤ 3 cmMaximum tumor size for covered treatment

9ICD-10 codes supporting medical necessity

3Alternative treatment categories that must be unsuitable

Procedure codes explicitly not covered

Medical Necessity and Exclusions

Medically Necessary Histotripsy

Histotripsy is considered medically necessary when ALL of the following criteria are met:

ALL of the following

Other methods have been reviewed by a multidisciplinary team and determined not to be suitable, including ALL of the following:
- Other well-established methods of ablation, including microwave or radiofrequency ablation, surgical ablation, or percutaneous ethanol injection.
- Arterially-directed therapies.
- Radiation therapy.
Member is 18 years of age or older.≥ 18 years
Tumors are 3 cm or smaller.≤ 3 cm

Histotripsy is not covered for tumors other than malignant liver tumors.

Histotripsy is not covered when any of the inclusion criteria are not met.

Histotripsy for malignant renal tissue or malignant pancreatic tissue is not covered, including imaging guidance, under codes 0888T and 1037T.

Code 0686T for histotripsy of malignant hepatocellular tissue, including image guidance, is not covered for Medicaid.

Experimental, investigational, or unproven treatment is excluded from coverage. Individual case review may allow coverage for care or treatment that is investigational yet promising for the conditions described. Requests for individual consideration require prior plan approval. All coverage determinations for experimental, investigational, or unproven treatment are made by a Priority Health medical director or clinical pharmacist. An exception to the exclusion may be reviewed when the condition is a terminal illness or a chronic, life-threatening, severely disabling disease causing serious clinical deterioration. Prior authorization requirements may apply; providers must submit a request demonstrating medical necessity when prior authorization is required. Refer to the Priority Health Provider Manual for more information.

Diagnosis and Procedure Codes

ICD-10 Codes that may support medical necessityICD-10

C22.0	Liver cell carcinoma (Hepatocellular carcinoma)
C22.1	Intrahepatic bile duct carcinoma (Cholangiocarcinoma)
C22.2	Hepatoblastoma
C22.3	Angiosarcoma of liver
C22.4	Other sarcomas of liver
C22.7	Other specified carcinomas of liver
C22.8	Malignant neoplasm of liver, primary, unspecified as to type
C22.9	Malignant neoplasm of liver, not specified as primary or secondary
C78.7	Secondary malignant neoplasm of liver and intrahepatic bile duct

CPT/HCPCS CodesCPTCovered

0686T

Histotripsy (ie, non-thermal ablation via acoustic energy delivery) of malignant hepatocellular tissue, including image guidance (Not covered for Medicaid)

Not CoveredCPTNot Covered

0888T	Histotripsy (i.e., non-thermal ablation via acoustic energy delivery) of malignant renal tissue, including imaging guidance
1037T	Histotripsy (ie, non-thermal ablation via acoustic energy delivery) of malignant pancreatic tissue, including imaging guidance

CPT/HCPCS CodesCPT

0686T

Histotripsy (ie, non-thermal ablation via acoustic energy delivery) of malignant hepatocellular tissue, including image guidance (Not covered for Medicaid)

Not CoveredCPTNot Covered

0888T	Histotripsy (i.e., non-thermal ablation via acoustic energy delivery) of malignant renal tissue, including imaging guidance
1037T	Histotripsy (ie, non-thermal ablation via acoustic energy delivery) of malignant pancreatic tissue, including imaging guidance

Member age requirement

Minimum member age18 years or older

Applies toHistotripsy of primary or metastatic malignant liver tumors

Coverage requirementThe member must meet this age criterion along with all other medical necessity criteria

Tumor size requirement

Maximum tumor size≤ 3 cm

Applies toTumors treated with histotripsy for primary or metastatic malignant liver tumors

Authorization and Documentation Requirements

Prior Authorization

Obtain prior plan approval for individual consideration

Requests for individual consideration of investigational yet promising treatment require prior plan approval. Coverage determinations for experimental, investigational, or unproven treatment are made by a Priority Health medical director or clinical pharmacist.

Documentation Required

Document multidisciplinary treatment review

Document multidisciplinary-team review showing that other well-established ablation methods, arterially directed therapies, and radiation therapy were considered and determined not suitable.

Other well-established ablation methods include microwave, radiofrequency, surgical ablation, or percutaneous ethanol injection.
Document review of arterially directed therapies.
Document review of radiation therapy.

Histotripsy Overview

Histotripsy is a noninvasive, nonionizing, nonsurgical treatment that uses focused ultrasound energy to create mechanical acoustic cavitation and destroy targeted tissue.

Key Terms and Technology

Histotripsy

HistotripsyNon-thermal ablation via acoustic energy delivery

MechanismMechanically destroys targeted tissue through acoustic cavitation

Treatment characteristicsA noninvasive, nonionizing, nonsurgical treatment option

Acoustic cavitation

Acoustic cavitationFormation, expansion, and collapse of microbubbles within tissue

Bubble formationUltrasound energy creates microbubbles in the gas within the extracellular matrix of tissues

Effect on tissue

Policy Summary

PayerPriority Health Medicare

PolicyHistotripsy for Malignant Liver Tumors

Policy CodePolicy N/A

Change TypeNew policy

Effective Date03/01/2026

Next Review DateN/A

SourceLink

On This Page

Coverage requirementThe tumor must measure 3 cm or less, along with all other medical necessity criteria

Documentation Required

Document eligibility and tumor size

Document that the treated lesion is a malignant liver tumor, the member is at least 18 years old, and the tumor measures 3 cm or less.

The tumor may be primary or metastatic.
Member age: 18 years or older.
Tumor size: 3 cm or less.

Denial Risk

Confirm the diagnosis and all criteria

Treatment is excluded when the tumor is not a malignant liver tumor or when any inclusion criterion is not met.

Confirm the diagnosis is a malignant liver tumor.
Confirm that all inclusion criteria are satisfied before requesting coverage.

Denial Risk

Rule out established treatment alternatives

Histotripsy may be denied when other established ablation methods, arterially directed therapies, or radiation therapy have not been reviewed by a multidisciplinary team and determined unsuitable.

Review other well-established ablation methods.
Review arterially directed therapies.
Review radiation therapy.
Document why each reviewed alternative is not suitable.

Denial Risk

Verify age and tumor-size limits

Treatment may be denied when the member is younger than 18 years or the tumor exceeds 3 cm.

Member must be 18 years of age or older.
Tumor must measure 3 cm or less.

Billing Rule

Do not bill noncovered renal or pancreatic histotripsy

Histotripsy of malignant renal tissue and malignant pancreatic tissue is not covered under codes 0888T and 1037T.

0888T: Histotripsy of malignant renal tissue, including imaging guidance.
1037T: Histotripsy of malignant pancreatic tissue, including imaging guidance.

Denial Risk

Address the investigational-treatment exclusion

Experimental, investigational, or unproven treatment is excluded from coverage unless an exception is reviewed. The exception may be reviewed only when the condition is a terminal illness or a chronic, life-threatening, severely disabling disease causing serious clinical deterioration.

Requests for an exception require prior plan approval.
Coverage determinations are made by a Priority Health medical director or clinical pharmacist.

The expanding and collapsing microbubbles mechanically destroy the targeted lesion or tissue

Edison Histotripsy System

Edison Histotripsy SystemA histotripsy system manufactured by HistoSonics

Ablation methodUses non-thermal mechanical ultrasound ablation to target and destroy malignant tissue

Clinical applicationProvides a noninvasive treatment option for malignant liver tumors, including nonresectable liver tumors