Modifiedselect_healthPolicy CCP.1528

Microwave thermotherapy (ablation) for lung and kidney tumors

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Policy governing coverage determinations for image-guided microwave ablation of primary or metastatic lung tumors and malignant kidney (renal) tumors for Select Health of South Carolina members, including clinical criteria for medical necessity and referenced guideline support.

Policy Summary

Payerselect_health

PolicyMicrowave thermotherapy (ablation) for lung and kidney tumors

Policy CodePolicy CCP.1528

Change TypeCoverage expanded (kidney added)guidelines updated

Effective DateAug 1, 2023

Last ReviewJul 1, 2025

Next Review DateNov 1, 20269d

Key ActionObtain prior authorization and document tumor size, staging, and that the patient is a non-surgical candidate or declines alternative definitive treatments.

SourceLink

POLICY UPDATE CHANGES

Coverage policy was updated in 2025 to include microwave ablation for kidney tumors as a covered service for appropriately selected patients.

Updated National Comprehensive Cancer Network guidelines for kidney and lung cancers to 2025 versions.

Coverage updated.

Policy references updated.

≤3 cmmax tumor diameter (lung)

≤3 cmmax tumor diameter (renal T1a)

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Modifiedselect_healthPolicy CCP.1528

Microwave thermotherapy (ablation) for lung and kidney tumors

Customize your policy alerts

Sign up for select_health Policy CCP.1528 alerts

Get alerted when Policy CCP.1528 changes without checking for updates manually.

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Policy Summary

Payerselect_health

PolicyMicrowave thermotherapy (ablation) for lung and kidney tumors

Policy CodePolicy CCP.1528

Change TypeCoverage expanded (kidney added)guidelines updated

Effective DateAug 1, 2023

Last ReviewJul 1, 2025

Next Review DateNov 1, 20269d

Key ActionObtain prior authorization and document tumor size, staging, and that the patient is a non-surgical candidate or declines alternative definitive treatments.

SourceLink

POLICY UPDATE CHANGES

Coverage policy was updated in 2025 to include microwave ablation for kidney tumors as a covered service for appropriately selected patients.

Updated National Comprehensive Cancer Network guidelines for kidney and lung cancers to 2025 versions.

Coverage updated.

Policy references updated.

≤3 cmmax tumor diameter (lung)

≤3 cmmax tumor diameter (renal T1a)

up to 6%renal major complications

3policy update events

Coverage Criteria for Microwave Ablation

Microwave ablation for primary or metastatic lung tumors

Covered when ALL of the following are met.

Lung ablation criteria: Member is either medically inoperable due to lesion location/extent or comorbid conditions, OR will not receive stereotactic ablative radiotherapy or definitive radiation therapy; AND a single tumor is less than or equal to 3 centimeters in size.single tumor ≤ 3 cm

Per NCCN and expert guidance; intended for primary or metastatic lung tumors

Microwave ablation for malignant kidney tumors

Covered when ALL of the following are met.

Renal ablation criteria: Member is not a candidate for surgery due to other medical conditions or presents a significant risk of illness or death from the procedure; AND the tumor is a clinical stage one renal lesion that is 3 centimeters or less in diameter.clinical stage I (T1a) lesion ≤ 3 cm

Policy updated 2025 to include kidney tumors as covered for appropriately selected patients

No explicit additional limitations or exclusions were identified in this policy segment during development. The policy text states: No limitations were identified during the writing of this policy, indicating that no further restrictions beyond the stated medical necessity criteria are documented here.

This document segment does not list any specific exclusion conditions. The policy's limitations section explicitly notes that No limitations were identified during the writing of this policy, and the policy update record (7/2025) indicates changes to coverage but does not add exclusion statements in this segment. Refer to the full policy for any exclusions that may appear elsewhere.

Clinical evidence and safety data include important caveats: effectiveness of microwave ablation decreases for tumors larger than 3 cm, and reported local recurrence rates are highly variable (approximately 9% to 37% in published series). Procedure-related complication rates are notable — for lung ablation the pneumothorax rate requiring chest tube ranges from 10% to 52%, with other reported risks including pleural effusion, pulmonary hemorrhage, and pulmonary infection. These findings, together with heterogeneity and retrospective designs of much of the literature, indicate evidence gaps and a need for prospective comparative trials. The policy was updated in 7/2025; see the full policy for details on how these evidence caveats affect specific medical necessity criteria.

This policy segment does not contain explicit 'not medically necessary' determinations. The update history notes that coverage was revised in July 2025; any formal 'not medically necessary' statements are located in the complete policy document and should be consulted there for definitive determinations.

Coding and Key Clinical Limits

Regulatory device code referencesmixed

NEY (product code)

FDA 510(k) product code search category for relevant microwave ablation devices

Maximum tumor diameter for covered ablation — clinical threshold

Maximum tumor diameter — lungSingle lung tumor ≤ 3 cm

Maximum tumor diameter — renal (policy threshold)Clinical stage I (T1a) renal lesion ≤ 3 cm

Rationale for size thresholdPolicy and NCCN guidance support microwave ablation for tumors typically 3 cm or smaller

Provider Actions, Documentation, and Prior Authorization

Prior Authorization

Prior authorization expected when medical necessity hinges on clinical criteria

Prior authorization is expected when coverage depends on documented clinical criteria such as tumor size, operability, and planned or declined alternative therapies; submit a PA when the medical necessity determination relies on these factors.

PA should be requested when coverage determination depends on tumor size (e.g., single lung tumor ≤ 3 cm or clinical stage T1a renal lesion ≤ 3 cm).
Include documentation of operability status and planned or declined alternative definitive therapies.

Prior Authorization

Prior authorization may be required after 7/2025 coverage update

Policy coverage was updated in July 2025; prior authorization requirements or processes may have changed and providers should verify current PA rules and codes before submission.

See the full policy for specific PA codes and processes following the 7/2025 coverage update.

Background and Rationale

Thermal tumor ablation is a minimally invasive, image-guided technique that induces coagulative necrosis by applying thermal energy. Microwave ablation delivers electromagnetic energy (commonly in the 900–2450 MHz range) via a percutaneously or surgically placed antenna to rapidly heat tissue, producing larger and faster ablation zones than some other modalities and reducing the heat-sink effect. Devices cleared for soft tissue ablation achieve temperatures sufficient for coagulative necrosis (for example, ≥54°C for ≥3 minutes or instantaneous temperatures of ~60°C).

Definitions and Guideline References

Microwave ablation — definition

DefinitionImage-guided percutaneous or surgical placement of a microwave antenna to deliver electromagnetic energy producing thermal coagulative necrosis (temperatures ≥54°C for ≥3 minutes or instant 60°C)

Access and guidanceAntenna placement is achieved using ultrasound, computed tomography, or fluoroscopic guidance depending on lesion location

Device componentsMicrowave systems include a generator, coaxial cable, and 14–17 gauge antenna

T1a renal lesion (policy-defined eligibility) — clinical stage definition and policy threshold note

Policy clinical definitionClinical stage I (T1a) renal lesion defined in this policy as a localized renal tumor that is 3 centimeters or less in diameter

Comparison to other definitions

Policy Summary

Payerselect_health

PolicyMicrowave thermotherapy (ablation) for lung and kidney tumors

Policy CodePolicy CCP.1528

Change TypeCoverage expanded (kidney added)guidelines updated

Effective DateAug 1, 2023

Last ReviewJul 1, 2025

Next Review DateNov 1, 20269d

Key ActionObtain prior authorization and document tumor size, staging, and that the patient is a non-surgical candidate or declines alternative definitive treatments.

SourceLink

On This Page

Step Therapy

Document consideration of alternative covered services

Document that alternative covered services were considered and whether they were unsuitable or declined (examples include radiofrequency ablation, cryoablation, surgical resection, stereotactic radiosurgery, and definitive radiation therapy).

List alternatives considered and clinical reasons they were not chosen (e.g., anatomic limitations, comorbidities, patient preference).
Reference guideline recommendations when applicable to support the decision.

Note

Include clinical rationale and supporting tumor data with requests

Provide clinical documentation that supports why microwave ablation is being requested for this patient — include tumor characteristics, prior treatments, and rationale linking patient-specific factors to the chosen therapy.

Include tumor size, location, staging, and imaging reports.
Describe prior therapies and the clinical reasoning for selecting microwave ablation.

Documentation Required

Document non-surgical candidacy or significant operative risk

Documentation must demonstrate the patient is a non-surgical candidate (medically inoperable) or is at significant operative risk of illness or death, with objective evidence supporting that determination.

Include statement of surgical candidacy and supporting comorbidity or risk assessments.
Provide multidisciplinary notes or surgical consultation findings when available.

Documentation Required

Include device regulatory information (FDA 510(k) product code NEY) when relevant

If device regulatory status is relevant to coverage documentation, note that the FDA 510(k) Premarket Notification database was searched using product code NEY; include device identification or clearance information when applicable.

Cite the FDA 510(k) search (product code NEY) and any applicable 510(k) number or device description in the request.

Denial Risk

Justify requests for lung tumors > 3 cm or when SABR/definitive RT is planned

Requests for microwave ablation for lung tumors larger than 3 centimeters, or for patients who will receive stereotactic ablative radiotherapy/definitive radiation therapy, require clear justification as they may not meet the policy's medical necessity criteria.

For lung lesions > 3 cm, provide compelling clinical rationale and supporting evidence if requesting coverage outside stated size criteria.
If definitive radiation therapy or stereotactic ablative radiotherapy is planned, document why microwave ablation is still clinically indicated.

Denial Risk

Coverage update (7/2025) may increase denial risk if documentation doesn't meet revised criteria

Because coverage was updated in July 2025, changes to coverage stance or criteria may lead to denials if documentation does not meet the revised policy requirements; confirm that submissions align with the current criteria.

Re-check eligibility criteria (size thresholds, operability, alternative therapy considerations) against the 7/2025 policy before submission.
Provide complete supporting documentation to reduce the risk of denial after the update.

Some sources define T1a as ≤4 cm, but this policy uses a ≤3 cm covered threshold for microwave ablation

Coverage conditionMember must be not a candidate for surgery due to medical conditions or present significant operative risk

NCCN guidance — NCCN Clinical Practice Guidelines referenced

NCCN kidney cancer guidelineNCCN Clinical Practice Guidelines in Oncology — Kidney cancer. Version 3.2025

NCCN non‑small cell lung cancer guidelineNCCN Clinical Practice Guidelines in Oncology — Non-small cell lung cancer. Version 4.2025

Guideline roleNCCN 2025 guidelines are cited as supporting guidance for coverage determinations in this policy