This Medical Policy is provided for informational purposes only.

If Members have any questions about the medical necessity of a service or procedure, they should discuss the question with their Network Provider or call a member of our Customer Service Team.

MEDICAL POLICY USE DISCLAIMER

  1. Medical Policy is used by Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company ("BCBSMS") as one set of guidelines (among other sets of guidelines) to assist BCBSMS in making benefit coverage decisions. BCBSMS utilizes Medical Policy adopted by our Medical Policy Advisory Committee ("MPAC") which is supported by the Blue Cross and Blue Shield Association Medical Policy, research and development. Medical Policies are the property of BCBSMS and any use of Medical Policy not agreed to by BCBSMS is strictly prohibited. The use of Medical Policy for purposes related to the health care of a BCBSMS plan member is permitted and is not a violation of the proprietary rights of BCBSMS.
  2. These Medical Policies are based on scientifically meritorious evidence provided through research for a particular medical technology. Medical Policy is also based on data from peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations.
  3. These Medical Policies apply to members/subscribers who have health insurance through BCBSMS. This Medical Policy also applies to Members of a self-insured group health plan for which Blue Cross & Blue Shield of Mississippi provides claims administration and persons covered by a Medicare Supplement policy offered by BCBSMS. This Medical Policy does not apply to any other individuals. Medical Policies may differ for Federal employees covered under the Federal Employees Health Benefits Plan.
  4. In the event of any conflict between this Medical Policy and any benefit plan, Summary Plan Description or other coverage document, the benefit plan, Summary Plan Description or other coverage document will govern.
  5. Medical technology is rapidly changing and these Medical Policies are subject to change without notice. Also, please be aware that as a result of ongoing changes being made to Medical Policy, BCBSMS cannot and does not guarantee that these Medical Policies are current.

BCBSMS Medical Policies are Subject to the Following Restrictions


This Medical Policy is provided for informational purposes only.

If Members have any questions about the medical necessity of a service or procedure, they should discuss the question with their Network Provider or call a member of our Customer Service Team.

MEDICAL POLICY USE DISCLAIMER

  1. Medical Policy is used by Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company ("BCBSMS") as one set of guidelines (among other sets of guidelines) to assist BCBSMS in making benefit coverage decisions. BCBSMS utilizes Medical Policy adopted by our Medical Policy Advisory Committee ("MPAC") which is supported by the Blue Cross and Blue Shield Association Medical Policy, research and development. Medical Policies are the property of BCBSMS and any use of Medical Policy not agreed to by BCBSMS is strictly prohibited. The use of Medical Policy for purposes related to the health care of a BCBSMS plan member is permitted and is not a violation of the proprietary rights of BCBSMS.
  2. These Medical Policies are based on scientifically meritorious evidence provided through research for a particular medical technology. Medical Policy is also based on data from peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations.
  3. These Medical Policies apply to members/subscribers who have health insurance through BCBSMS. This Medical Policy also applies to persons covered by the Mississippi Children's Health Insurance Program, Members of a self-insured group health plan for which Blue Cross & Blue Shield of Mississippi provides claims administration and persons covered by a Medicare Supplement policy offered by BCBSMS. This Medical Policy does not apply to any other individuals. Medical Policies may differ for Federal employees covered under the Federal Employees Health Benefits Plan.
  4. In the event of any conflict between this Medical Policy and any benefit plan, Summary Plan Description or other coverage document, the benefit plan, Summary Plan Description or other coverage document will govern.
  5. Medical technology is rapidly changing and these Medical Policies are subject to change without notice. Also, please be aware that as a result of ongoing changes being made to Medical Policy, BCBSMS cannot and does not guarantee that these Medical Policies are current.

BCBSMS Medical Policies are Subject to the Following Restrictions


This Medical Policy is provided for informational purposes only.

If Members have any questions about the medical necessity of a service or procedure, they should discuss the question with their Network Provider or call a member of our Customer Service Team.

MEDICAL POLICY USE DISCLAIMER

  1. Medical Policy is used by Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company ("BCBSMS") as one set of guidelines (among other sets of guidelines) to assist BCBSMS in making benefit coverage decisions. BCBSMS utilizes Medical Policy adopted by our Medical Policy Advisory Committee ("MPAC") which is supported by the Blue Cross and Blue Shield Association Medical Policy, research and development. Medical Policies are the property of BCBSMS and any use of Medical Policy not agreed to by BCBSMS is strictly prohibited. The use of Medical Policy for purposes related to the health care of a BCBSMS plan member is permitted and is not a violation of the proprietary rights of BCBSMS.
  2. These Medical Policies are based on scientifically meritorious evidence provided through research for a particular medical technology. Medical Policy is also based on data from peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations.
  3. These Medical Policies apply to members/subscribers who have health insurance through BCBSMS. This Medical Policy also applies to persons covered by the Mississippi Children's Health Insurance Program, Members of a self-insured group health plan for which Blue Cross & Blue Shield of Mississippi provides claims administration and persons covered by a Medicare Supplement policy offered by BCBSMS. This Medical Policy does not apply to any other individuals. Medical Policies may differ for Federal employees covered under the Federal Employees Health Benefits Plan.
  4. In the event of any conflict between this Medical Policy and any benefit plan, Summary Plan Description or other coverage document, the benefit plan, Summary Plan Description or other coverage document will govern.
  5. Medical technology is rapidly changing and these Medical Policies are subject to change without notice. Also, please be aware that as a result of ongoing changes being made to Medical Policy, BCBSMS cannot and does not guarantee that these Medical Policies are current.

BCBSMS Medical Policies are Subject to the Following Restrictions

Medical Policy Search
Printer Friendly Version Radiofrequency Ablation (RFA) of Primary or Metastatic Liver Tumors

Radiofrequency Ablation (RFA) of Primary or Metastatic Liver Tumors

 

DESCRIPTION

 In radiofrequency ablation (RFA), a probe is inserted into the center of a tumor and the non-insulated electrodes, which are shaped like prongs, are projected into the tumor, heat is generated locally by a high frequency, alternating current that flows from the electrodes. The local heat treats the tissue adjacent to the probe resulting in a 3 cm. to 5 cm. sphere of dead tissue. The cells killed by RFA are not removed, but are gradually replaced by fibrosis and scar tissue. If there is local recurrence, it occurs at the edge, and in some cases may be retreated. Radiofrequency ablation may be performed percutaneously, laparoscopically, or as an open procedure.

Hepatic tumors can arise either as primary liver cancer or by metastasis to the liver from other tissues. Local therapy for hepatic metastasis is indicated only when there is no extrahepatic disease, which rarely occurs for patients with primary cancers other than colorectal carcinoma or certain neuroendocrine malignancies. At present, surgical resection with adequate margins or liver transplantation consitutes the only treatments available with demonstrated curative potential. However, the majority of hepatic tumors are unresectable at diagnosis, due either to their anatomic location, size, number of lesions, or underlying liver reserve. 

Neuroendocrine tumors are tumors of cells that possess secretory granules and originate from the neuroectoderm. Neuroendocrine cells have roles both in the endocrine system and the nervous system. They produce and secrete a variety of regulatory hormones, or neuropeptides, which include neurotransmitters and growth factors. Overproduction of the specific neuropeptides produced by the cancerous cells causes a variety of symptoms depending on the hormone produced. They are rare, with an incidence of 2-4 per 100,000 per year. Treatment of liver metastases is undertaken to prolong survival and reduce endocrine-related symptoms as well as symptoms related to the hepatic mass.

Radiofrequency ablation (RFA) has been investigated as a treatment for unresectable hepatic tumors, both as primary treatment and as a bridge to liver transplant. In the latter setting, it is hoped that RFA will reduce the incidence of tumor progression, and thus maintain a patients's candidacy for liver transplant during the wait time for a donor organ. This technique involves inserting an electrode into the center of the tumor with the delivery of alternating current. Protein denaturation and coagulation is the ultimate cause of cell death. Radiofrequency ablation may be performed percutaneously, laparoscopically, or as an open procedure.

Various locoregional therapies for unresectable liver tumors have been investigated: radiofrequency ablation, cryosurgical ablation, laser ablation, trans-hepatic artery embolization/chemoembolization, microwave coagulation, and percutaneous ethanol injection. Hyperthermia may be performed in conjunction with the above procedures. Hyperthermia is considered separately in another policy

Note: Radiofrequency ablation of extrahepatic tumors is addressed separately in another policy.

 

POLICY

 Radiofrequency ablation (RFA) of primary hepatocellular carcinoma (HCC) may be considered medically necessary as a primary treatment of HCC for patients who are not candidates for curative therapy (resection or transplant) when there are no more than 3 nodules and when all tumor foci can be adequately treated.

Radiofrequency ablation of primary hepatocellular carcinoma (HCC) is considered medically necessary as a bridge to transplant, where the intent is to prevent further tumor growth and to maintain a patient’s candidacy for liver transplant.

Radiofrequency ablation (RFA) of primary hepatocellular carcinoma (HCC) is considered investigational when there are more than three nodules or when not all sites of tumor foci can be adequately treated.

Radiofrequency ablation may be considered medically necessary as a primary treatment of hepatic metastases 5 cm or less in diameter from colorectal cancer in the absence of extrahepatic metastatic disease if tumor foci are deemed by the attending surgeon to be technically unresectable or patients are precluded from definitive hepatic resection due to underlying condition(s) and, in either case, when all tumor foci can be adequately treated.

Radiofrequency ablation may be considered medically necessary as treatment of hepatic metastases from neuroendocrine tumors in patients with symptomatic disease when systemic therapy has failed to control symptoms.

Radiofrequency ablation for hepatic metastasis is considered investigational for the following:

  • Hepatic metastases from colorectal cancer or neuroendocrine tumors that do not meet the criteria above; and
  • Hepatic metastases from other types of cancer  

POLICY EXCEPTIONS

 None

 

POLICY GUIDELINES

 Explicit criteria have not been established for radiofrequency ablation of primary or metastatic hepatocellular cancer. Candidacy is based on a number of factors including number of tumor foci, and accessibility. In general, published studies have included patients with four 4-5or fewer hepatic lesions measuring 5 cm or less using current technology. Compiled evidence suggests RFA at open laparotomy may provide superior outcomes compared to the percutaneous route, but the lack of comparative trials, and patient selection bias in indirect comparisons, do not permit definitive conclusions.

Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

 

POLICY HISTORY

 2/2000: Approved by Medical Policy Advisory Committee (MPAC)

8/2000: Reviewed by MPAC, investigational status maintained.

12/12/2000: Federal Employee Program allows coverage, see "Policy Exceptions"

5/21/2001: Codes Reference section revised

2/8/2002: Investigational definition added

3/13/2002: New 2002 codes added, CPT code 76490 added

5/2/2002: Type of Service and Place of Service deleted

6/11/2002: CPT code 47399 deleted

3/25/2004: Reviewed by MPAC, investigational status changed to medically necessary, Policy section aligned with BCBSA

5/3/2004: Code Reference section updated, CPT code 47380 "for imaging guidance, use 76490" deleted, CPT code 47382 "for imaging guidance and monitoring, see code 76490" deleted, CPT code 76490 deleted, CPT 76940 added

7/27/2006:Policy updated. Updates approved per Medical Policy Advisory Committee (MPAC)

9/1/2006: Code reference section updated. Diagnosis code 197.7 deleted from covered table.

9/22/2006: Coding updated. ICD9 2006 revisions added to policy

1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions

6/19/2007: Policy statement updated; RFA as a primary treatment of hepatic metastases from colorectal cancer in the absence of extrahepatic metastatic disease may be considered medically necessary when the tumor cannot be removed by surgical resection, or precluded by underlying condition(s), and when all tumor foci can be treated. Added RFA for hepatic metastases from colorectal cancer that do not meet policy criteria, and from other types of cancer is considered investigational to policy statement.

12/31/2008: Policy reviewed, no changes

1/06/2009: Policy reviewed. No changes.

9/30/2009: Code reference section updated. New ICD9 procedure code 17.63 added to covered table. 

01/08/2010:  Code Reference Section updated.  Removed deleted CPT Codes 76362 & 76394.  Add the following ICD-9 Diagnosis codes: 155.2 and 197.7 (Diagnosis Code 197.7 must be billed with one of the following malignant neoplasm of colon ICD-9 Diagnosis codes: 153.0 - 153.9)

09/10/2010:  Policy description updated to add information regarding neuroendocrine tumors. Added policy statement to indicate that RFA may be considered medically necessary for hepatic metastases from neuroendocrine tumors in patients with symptomatic disease when systemic therapy has failed to control symptoms. The first policy statement was revised to state that RFA of primary HCC may be considered medically necessary for patients who are not candidates for curative therapy (resection or transplant) when there are no more than 3 nodules and when all tumor foci can be adequately treated.  The policy (no spelling suggestions) regarding RFA as a bridge to transplant was changed from investigational to medically necessary where the intent is to prevent further tumor growth and to maintain a patient’s candidacy for liver transplant. RFA of primary HCC remains investigational when not all sites of tumor foci can be adequately treated or when there are more than three nodules.  Added ICD-9 code 209.72 to the Covered Codes table.

08/03/2011: Policy reviewed. Policy statement unchanged. Deleted outdated references from the Sources section.

09/25/2012: Policy reviewed; no changes.

 

SOURCE(S)

 Blue Cross Blue Shield Association policy # 7.01.91

 

CODE REFERENCE

 This is not intended to be a comprehensive list of codes. Some covered procedure codes have multiple descriptions.

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document.

Covered Codes

Code Number

Description

CPT-4

47370

Laparoscopy, surgical, ablation of one or more liver tumor(s); radiofrequency For imaging guidance, use 76940

47380

Ablation, open, of one or more liver tumor(s); radiofrequency

For imaging guidance, use 76940

47382

Ablation, one or more liver tumor(s), percutaneous, radiofrequency

For imaging guidance and monitoring, use 76940, 77013 or 77022

76940Ultrasound guidance for, and monitoring of, parenchymal tissue ablation
77013Computerized tomography guidance for; and monitoring of, parenchymal tissue ablation
77022Magnetic resonance guidance for, and monitoring of, parenchymal tissue ablation

ICD-9 Procedure

17.63

Laser interstitial thermal therapy [LITT] of lesion or tissue of liver under guidance (new 10-1-2009)

50.23Open ablation of liver lesion or tissue
50.24Percutaneous ablation of liver lesion or tissue  
50.25Laparoscopic ablation of liver lesion or tissue  
50.26Other and unspecified ablation of liver lesion or tissue

50.29

Other destruction of lesion of liver

ICD-9 Diagnosis

155.0

Liver, primary

155.2Liver, not specified as primary or secondary
197.7

Secondary malignant neoplasm; liver, specified as secondary

(ICD-9 Diagnosis Code 197.7 must be billed with one of the following malignant neoplasm of colon ICD-9 Diagnosis Codes:  153.0 - 153.9)

209.72Secondary neuroendocrine tumor of liver  (Added 09-10-2010)

HCPCS

 

 

 

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