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Medical Policy: 07.01.37
Original Effective Date: March 2007
Reviewed: August 2011
Revised: March 2008
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:
Radiofrequency ablation (RFA) is used to treat inoperable tumors or to treat patients ineligible for surgery due to age, presence of comorbidities, or poor general health. The goals of RFA may include controlling local tumor growth and preventing recurrence; palliating symptoms; and extending survival duration for patients with certain tumors.
The procedure kills cells, cancerous as well as normal, by applying a heat-generating rapidly alternating current through probes inserted into the tumor. The effective volume of RFA depends on the frequency and duration of applied current, local tissue characteristics, and probe configuration. RFA can be performed as an open surgical procedure, laparoscopically, or percutaneously with ultrasound or computed tomography guidance.
Cryosurgical ablation, also known as cryosurgery, involves freezing of target tissues, most often by inserting a probe into the tumor through which coolant is circulated.
Cryosurgical probes are cooled to extremely low temperatures using liquid nitrogen or liquid argon and then allowed to warm up. The freeze-thaw cycle is repeated until the entire tumor is encompassed in an ice ball.
Cryosurgery may be performed as an open surgical procedure, with laparoscopic technique or percutaneously with ultrasound or magnetic resonance imaging guidance.
Repeated cryoablation procedures may be required if tumors recur or are not fully ablated after the initial procedure.
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Prior Approval:
Not applicable
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Policy:
Cryosurgical ablation and cryosurgical ablation may be considered medically necessary to treat localized renal cell carcinoma that is no more than 4 cm in size when one of the following criteria is met:
- Preservation of kidney function is necessary (i.e., the patient has one kidney or renal insufficiency defined by a glomerular filtration rate [GFR] of less than 60 mL/m2) and standard surgical approach (i.e., resection of renal tissue) is likely to substantially worsen kidney function; or
- Patient is not considered a surgical candidate
This policy relates only to renal tumors. For policies related to other tumors, refer to Policy #07.01.19; Radiofrequency and Cryoablation of Liver Tumors or to Policy # 07.01.07; Cryoablation for Prostate Cancer.
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Procedure Codes and Billing Guidelines:
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To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
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50542 Laparoscopy, surgical; ablation of renal mass lesion(s)
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50592 Ablation, one or more renal tumor(s), percutaneous, unilateral, radiofrequency
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50250 Ablation, open, one or more renal mass lesion(s), cryosurgical, including intraoperative ultrasound, if performed
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50593 Ablation, renal tumor(s), unilateral, percutaneous, cryotherapy
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Selected References:
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McDougal WS, Gervais DA, et al. Long-term followup of patients with renal cell carcinoma treated with radio frequency ablation with curative intent. J Urol. 2005 Jul;174(1):61-3.
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Varkarakis IM, Allaf ME, et al. Percutaneous radio frequency ablation of renal masses: results at a 2-year mean followup. J Urol. 2005 Aug;174(2):456-60.
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Matsumoto ED, Johnson DB, et al. Short-term efficacy of temperature-based radiofrequency ablation of small renal tumors. Urology. 2005 May;65(5):877-81.
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Weizer AZ, Raj GV, et al. Complications after percutaneous radiofrequency ablation of renal tumors. Urology. 2005 Dec;66(6):1176-80.
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Gill IS, Novick AC, et al. Laparoscopic renal cryoablation in 32 patients. Urology. 2000 Nov 1;56(5):748-53.
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Rukstalis DB, Khorsandi M, et al. Clinical experience with open renal cryoablation. Urology. 2001 Jan;57(1):34-9.
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Nadler RB, Kim SC, et al. Laparoscopic renal cryosurgery: the Northwestern experience. J Urol. 2003 Oct;170(4 Pt 1):1121-5.
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Shingleton WB, Sewell PE Jr. Cryoablation of renal tumours in patients with solitary kidneys. BJU Int. 2003 Aug;92(3):237-9.
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Carey R; Leveillee R. First prize: Direct real-time temperature monitori. J Endourol 2007 Aug;21(8):807-13.
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Thiel D; Winfield H. State-of –the-art Surgical management of renal cell. Expert Rev Anticancer Ther 2007 Sep;7(9):1285-94.
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Stern J; Svatej R; Park S; Hermann M; Lotan Y; Sagalowsky A; Cadeddu JA. Intermediate Comparison of partial nephrectomy and radiofrequency ablation for clinical T1a renal tumor. BJU Int 2007 Aug;(100(2):287-90.
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Hafron J; Kaouk J; Ablative techniques for the management of kidney Cancer. Nat Clin Pract Urol 2007 May; 4(5):261-9.
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Wile G; Leyendecker J; Krehbiel K; Dyer R; Zagoria R. CT and MR Imaging after inaging –guided thermal ablation of renal neoplasms. Radiographics 2007 Mar-Apr;27(2):325-39; discussion 339-40.
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Liapi E; Geschwind J. Transcatheter and ablative therapeutic approaches. J Clin Oncol 2007 Mar 10;25(8):978-86.
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Davol PE,Fulmer BR, Rukstalis DB. Long-term results of Cryoablation for renal cancer and compelx renal masses, Urology 2006Jul;68 (1 Suppl):2-6.
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O’Malley RL, Berger AD, Kanofsky JA, Phillips CK, Stifelman M, Taneja SS. A matched-cohort comparisonof laparoscopic Cryoablation and laparoscopic partial nephrectomy for treating renal masses. BJU Int. 2007 Feb;99(2):395-8 Epub 2006 Dec 1.
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Bandi G, Hedican SP, Makada SY, Current practice patterns in the use of ablation technology for the management of small renal masses at academic centers in the United States. Urology. 2008Jan;71 (1):113-7.
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Abdellaoui A, Watkinson AF. Radiofrequency ablation of renal cell tumors. Future Oncol. 2008 Feb;4(1):103-11.
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Ramirez ML, Evans CP. Current management of small renal masses. Can J Urol. 2007 Dec;14 Suppl 1:39-47.
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Policy History:
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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.
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