Radiofrequency Ablation of Tumors Outside the Liver
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Medicare medical policy governing when RFA techniques to destroy non-liver tumors are considered medically necessary for Providence Health Plan Medicare members; excludes liver tumors and addresses only RFA (not other ablation modalities).
Interim update; add clarifying language.
Coverage Criteria for RFA of Non-Liver Tumors
Medicare internal criteria application
Covered when Company medical policy criteria are met and Medicare coverage criteria are not fully established for RFA of non-liver tumors.
See Policy Guidelines and Medicare Coverage Criteria notes.
This policy specifically excludes treatment of the liver. It does not address liver tumors (primary or metastatic); providers should refer to the separate Medical Policy MP265 — Liver Tumor Treatment for coverage guidance on hepatic tumor ablation.
Services described in this policy are considered covered for Medicare members only when the Company’s medical policy criteria are met. When the Company criteria are not met, the services are considered not medically necessary for Medicare members and will be denied. All unlisted procedure codes submitted will be reviewed at the claim level for medical necessity, correct coding, and pricing; if an unlisted code is submitted for a non-covered service described in this policy it will be denied as not covered. To avoid post-service denial, prior authorization is recommended when using unlisted CPT codes for potentially covered services.
Coding and Code References
| 19499 | Unlisted procedure, breast |
| 20982 | Ablation therapy for reduction or eradication of 1 or more bone tumors, percutaneous, radiofrequency |
| 31641 | Bronchoscopy with destruction of tumor or relief of stenosis by any method other than excision |
| 32998 | Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) percutaneous, radiofrequency, unilateral |
| 32999 | Unlisted procedure, lungs and pleura |
| 45399 | Unlisted procedure, colon |
| 50542 | Laparoscopy, surgical; ablation of renal mass lesion(s), including intraoperative ultrasound guidance and monitoring, when performed |
| 50549 | Unlisted laparoscopy procedure, renal |
| 50592 | Ablation, 1 or more renal tumor(s), percutaneous, unilateral, radiofrequency |
| 58580 | Transcervical ablation of uterine fibroid(s), including intraoperative ultrasound guidance and monitoring, radiofrequency |
Provider Actions, Prior Authorization, and Billing Guidance
Prior authorization recommended for unlisted codes
Prior authorization is recommended when reporting unlisted CPT procedure codes that may represent services covered under this policy to avoid post‑service denial.
- Examples: use prior authorization for any unlisted CPT codes submitted for potentially covered RFA procedures outside the liver.
Submit correct codes and supporting documentation
Provide documentation and coding that supports medical necessity when submitting unlisted procedure codes; follow prior authorization guidance for potentially covered services.
Claim‑level review of unlisted procedure codes
All unlisted procedure codes submitted will be reviewed at the claim level for medical necessity, correct coding, and pricing; submit documentation that justifies the procedure and supports coding and medical necessity.
- Documentation should demonstrate indication, procedure details, and why no specific CPT code accurately describes the service.
- Prior authorization is recommended when using unlisted codes for potentially covered services to prevent post‑service denial.
Unlisted codes for non‑covered services will be denied
If an unlisted CPT code is used to report a service that is not covered by this policy (services to which this policy’s non‑coverage applies), the claim will be denied as not covered.
- Unlisted codes submitted for potentially covered services should have prior authorization to avoid post‑service denial.
- Inclusion or omission of a code in this policy does not guarantee reimbursement or coverage.
Background and Scope
Radiofrequency ablation (RFA) is a percutaneous or surgical technique that destroys tumor tissue using thermal energy. This policy governs the use of RFA applied to tumors outside the liver (for example, bone, lung, kidney, thyroid, colon, breast, and uterine fibroids) and addresses only the RFA modality; other ablation modalities such as cryotherapy or laser are not covered by this RFA-specific policy and may be addressed in separate policies.
Definitions
Policy Revision History
Interim update adding clarifying language to the policy.
Annual review with no change to clinical criteria (listed as part of 1/2026 entry referencing prior annual review).
Annual review and Q1 2025 code update applied to the policy.
Q1 2024 code update and interim update with updated Company medically necessary criteria for RFA of uterine fibroids for Medicare.
Interim update adding a relevant unlisted code.
New Medicare Advantage medical policy created.
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