|
Medical Policy: 07.01.19
Original Effective Date: July 2001
Reviewed: December 2011
Revised: December 2010
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Primary and metastatic tumors in the liver are difficult to treat. While surgical resection is still considered the treatment of choice, many patients cannot tolerate resection due to poor hepatic reserve or the presence of disease beyond the liver. Radiofrequency ablation and cryoablation offer less invasive alternatives for treatment of liver tumors, especially those that are not amenable to surgical resection.
Radiofrequency ablation is a method of using electrical energy to ablate primary and metastatic tumors of the liver. A radiofrequency ablation probe is placed directly into the tumor by laparoscopy or laparotomy. The probe delivers a high-frequency current that produces heat and destroys the tumor. Normally the procedure requires less than 15 minutes exposure time and does not sacrifice surrounding normal liver tissue. Radiofrequency ablation may also be combined with surgical resection.
Cryoablation is a technique that uses extremely low temperatures to destroy tumors. The tumor is exposed to a rapid cycle of freezing and thawing until necrosis occurs. As with radiofrequency ablation, cryoablation is a focal therapy that allows treatment of specific lesions without destroying normal tissue. Cryoablation can also be performed as an aid in segmental resections.
Both radiofrequency ablation and cryoablation have been shown to expand the possibilities of tumor control when combined with surgical resection and contribute to the slowing of disease progression in patients with primary or metastatic tumors of the liver. Both treatments can provide palliative therapy in patients with hepatic tumors not amenable to surgical resection.
 Top
Prior Approval:
Not applicable
Top
Policy:
Radiofrequency ablation of liver tumors, with or without surgical resection, and cryoablation of liver tumors, with or without surgical resection may be considered medically necessary for any of the following indications:
- As primary treatment of primary hepatocellular carcinoma when all tumor foci can be adequately treated
- As primary treatment of hepatic metastases from colorectal cancer in the absence of extrahepatic metastases when all tumor foci can be adequately treated
- As a treatment of hepatic metastases from neuroendocrine tumors in patients with symptomatic disease when systemic therapy has failed to control symptoms
- As a bridge to transplant when the intent is to prevent further tumor growth and to maintain a patient’s candidacy for liver transplant
Radiofrequency ablation of liver tumors, with or without surgical resection, and cryoablation of liver tumors, with or without surgical resection is considered investigational for all indications not listed above, including but not limited to the following:
- As a means to downstage hepatocellular carcinoma in patients being considered for liver transplant
- To treat hepatic metastases from cancers other than colorectal cancer and neuroendocrine tumors as described above
- When performed as an alternative to surgery for patients with liver tumors that are assessed as resectable
- When not all sites of tumor foci can be adequately treated
See also medical policy 07.01.27 Radiofrequency and Cryosurgical Ablation of Renal Tumors
Top
Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
The following CPT codes may be used to report radiofrequency and cryoablation procedures involving the liver:
- 47370 Laparoscopy, surgical, ablation of one or more liver tumor(s), radiofrequency
- 47371 Laparoscopy, surgical, ablation of one or more liver tumor(s), cryosurgical
- 47380 Ablation, open, of one or more liver tumor(s), radiofrequency
- 47381 Ablation, one or more liver tumor(s), cryosurgical
- 47382 Ablation, one or more liver tumor(s), percutaneous, radiofrequency
- 47399 Unlisted procedure, liver
- 76940 Ultrasound guidance for, and monitoring of, visceral tissue ablation
Top
Selected References:
- Korpan NN. Hepatic cryosurgery for liver metastases. Annals of Surgery 1997; 225(2):193-201.
- Saliken JC, McKinnin G, Gray RR, Benjamin C, Rewcastle J. Liver cryosurgery with curative intent: Can we realize promise? Canadian Association of Radiologists Journal. October 1999; 50(5):295-297.
- Neifeld JP. Is cryosurgery appropriate treatment for hepatic malignancies? Journal of Surgical Oncology. 1999; 70:69-70.
- Oshowo A, Gillams A, Harrison E, Lees WR, Taylor I. Comparison of resection and radiofrequency ablation for treatment of solitary colorectal liver metastases. Br J Surg. 2003 Oct;90(10):1240-3.
- Giorgi A, Tarantino L, de Stefano G, Scala V, et al. Percutaneous sonographically guided saline-enhanced radiofrequency ablation of hepatocellular carcinoma. AJR Am J Roentgenol. 2003 Aug;181(2):479-84.
- Adam R, Hagopian EJ, Linhares M, Krissat J, et al. A comparison of percutaneous cryosurgery and percutaneous radiofrequency for unresectable hepatic malignancies. Arch Surg. 2002 Dec;137(12):1332-9; discussion 1340.
- Lenciono RA, Allgaier HP, Cioni D, Olschewski M, et al. Small hepatocellular carcinoma in cirrhosis: randomized comparison of radio-frequency thermalablation cersus percutaneous ethanol injection. Radiology. 2003 Jul;228(!):235-40. Epub 2003 May 20.
- Shibata T, Iimuro Y, Yamamoto T, Maetani Y, et al. Small hepatocellular carcinoma; comparison of radio-frequency ablation and percutaneous microwave coagulation therapy. Radiology. 2002 May;223(2):331-7.
- Wood TF, Rose DM, Chung M, Allegra DP, et al. Radiofrequency ablation of 231 unresectable tumors: indications, limitations, and complications. Ann Surg Oncol. 2000 Sep;7(8):593-600.
- Gillams AR, Lees WR. Radiofrequency ablation of colorectal live metastases. Abdom Imaging. 2005 Jul-Aug; 30(4):419-26.
- Chen MH, Wang W, Yan K et al. Treatment efficacy of radiofrequency ablation of 338 patients with hepatic malignant tumor and the relevant complications. World J Gastroenterol. 2005 Oct 28; 11(40):6395-401.
- Amersi FF, McElrath-Garza A, ahmad A et al. Long-term survival after radiofrequency ablation of complex resectable liver tumors. Arch Surg 2006 Jun; 141(6):581-7.
- Joosten J, Jager g, Oyen W et al. Cryosurgery and radiofrequency ablation for unresectable colorectal liver metastases. Eur J Surg Oncol 2005 Dec; 31(10):1152-9.
- Seifert JK, Springer A, Baier P et al. Liver resection or cryotherapy for colorectal liver metastases: A prospective case control study. Int J Colorectal Dis 2005 Aug; 19(4);585-94.
- McKay A, Dixon E, Taylor M. Current role of radiofrequency ablation for the treatment of colorectal liver metastases. Br J Surg. 2006 Oct;93(10):1192-201.
- Ruers TJ, Joosten JJ, Wiering B et al. Comparison between local ablative therapy and chemotherapy for non-resectable colorectal liver metastases: a prospective study. Ann Surg Oncol. 2007 Mar;14(3):1161-9.
- Eriksson J, Stalberg P, Nilsson A et al. Surgery and radiofrequency ablation for treatment of liver metastases from midgut and foregut carcinoids and endocrine pancreatic tumors. World J Surg. 2008; 32(5): 930-38.
- Berber E, Siperstein A. Local recurrence after laparoscopic radiofrequency ablation of liver tumors: an analysis of 1032 tumors. Ann Surg Oncol. 2008; 15(10):2757-2764.
- Cho YK, Kim JK, Kim MY et al. Systematic review of randomized trials for hepatocellular carcinoma treated with percutaneous ablation therapies. Hepatology 2009; 49(2):453-9.
- Meloni MF, Andreano A, Laedeke PF et al. Breast cancer liver metastases: US-guided percutaneous radiofrequency ablation-intermediate and long-term survival rates. Radiology 2009; 253(3):861-9.
- Pomfret EA, Washburn K, Wald C. Report of a national conference on liver allocation in patients with hepatocellular carcinoma in the United States. Liver Transpl 2010; 16(3):262-78.
- Wong SL, Mangu PB, Choti MA et al. American Society of Clinical Oncology 2009 Clinical Evidence Review on Radiofrequency Ablation of Hepatic Metastases for Colorectal Cancer. J Clin Oncol. Jan 20, 2010; 28(3):493-508.
- Gervais DA, Goldberg SN, Brown DB et al. Society of Interventional Radiology Position Statement on Percutaneous Radiofrequency Ablation for the treatment of Liver Tumors. J Vasc Interv Radiol 2009; 20:S342-S347.
- Van Tilborg AA, Meijerink MR, Sietses C et al. Long-term results of radiofrequency ablation for unresectable colorectal liver metastases: a potentially curative intervention. Br J Radiol. 2011 Jun; 84(1002):556-65. Epub 2010 Dec 15.
- Guenette JP, Dupuy DE. Radiofrequency ablation of colorectal hepatic metastases. J Surg Oncol. 2010 Dec 15; 102(8):978-87.
- McWillimas JP, Yamaoto S, Raman SS et al. Percutaneous abalation of hepatocellular carcinoma: current status. J Vasc Interv Radiol. 2010 Aug; 21(8 Suppl):S204-13.
Top
Policy History:
Date Reason Action
December 2010 Annual review Policy revised
December 2011 Annual review Policy renewed
Top
Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
|
 |
