Cryosurgical Ablation of Breast Cancer and Fibroadenoma Printer-Friendly Version   

Medical Policy: 07.01.28 
Original Effective Date: June 2005 
Reviewed: November 2007 
Revised:  

This policy applies to all products unless specific contract limitations, exclusions or exceptions apply. Please refer to the member's coverage manual for benefit availability. Managed care guidelines related to referral authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply.

Description: 

Cryosurgical ablation (hereafter referred to as cryosurgery) involves freezing of target tissues, most often by inserting into the tumor a probe through which coolant is circulated. Cryosurgery may be performed as an open surgical technique or as a closed procedure under laparoscopic or ultrasound guidance.

The hypothesized advantages of cryosurgery include improved local control and benefits common to any minimally invasive procedure (e.g., preserving normal organ tissue, decreasing morbidity, decreasing length of hospitalization).  Potential complications of cryosurgery include those caused by hypothermic damage to normal tissue adjacent to the tumor, structural damage along the probe track, and secondary tumors, if cancerous cells are seeded during probe removal.

Cryosurgery has been investigated as a treatment of breast cancer and fibroadenomas. Early-stage primary breast tumors are treated surgically. The selection of lumpectomy, modified radical mastectomy, or another approach balances the patient’s desire for breast conservation, the need for tumor-free margins in resected tissue, and the patient’s age, hormone receptor status, and other factors.  Adjuvant radiation therapy decreases local recurrences, particularly for those who select lumpectomy. Adjuvant hormonal therapy or chemotherapy are added, depending on the presence and number of involved nodes, hormone receptor status, and other factors. Treatment of metastatic disease includes surgery to remove the primary lesion and combination chemotherapy.  Fibroadenomas are common, benign tumors of the breast that can either present as a palpable mass or a mammographic abnormality. These benign tumors are frequently surgically excised to rule out a malignancy.

Policy: 

Cryoablation of breast cancer or fibroadenomas is considered investigational.

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Procedure Codes and Billing Guidelines: 

To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.

• Use CPT code 19105 Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma

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Selected References: 

• Littrup, PJ, Freeman-Gibb, L, et al. Cryotherapy for breast fibroadenomas. Radiology. 2005;234(1):63-72.
• Morin, J, Traore, A, et al. Magnetic resonance-guided percutaneous cryosurgery of breast carcinoma: technique and early clinical results.   Can J Surg. 2004;47(5):347-51.
• Kaufman, CS, Bachman, B, et al.   Office-based ultrasound-guided cryoablation of breast fibroadenomas. Am J Surg . 2002;184(5):394-400.
• Kaufman, CS, Bachman, B, et al.   Cryoablation treatment of benign breast lesions with 12-month follow-up. Am J Surg. 2004;188(4):340-8.
• Pfleiderer, SO, Freesmeyer, MG, et al.   Cryotherapy of breast cancer under ultrasound guidance: initial results and limitations. Eur Radiol. 2002;12(12):3009-14.
• Kaufman, CS, Rewcastle, JC. Cryosurgery for breast cancer. Technol Cancer Res Treat. 2004;3(2):165-75.
• Sabel, MS, Kaufman, CS, et al. Cryoablation of early-stage breast cancer: work-in-progress report of a multi-institutional trial. Ann Surg Oncol. 2004;11(5):542-9.
• Caleffi, M, Filho, DD, et al.   Cryoablation of benign breast tumors: evolution of technique and technology. Breast. 2004;13(5):397-407.

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Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave
Des Moines, Iowa 50309

*Current Procedural Terminology © 2008 American Medical Association. All Rights Reserved.

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.