Policy Application
All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.
Isolated Peripheral Non-Small Cell Lung Cancer
RFA may be considered medically necessary to treat an isolated peripheral non-small-cell lung cancer lesion when
ALL
the following criteria are met:
-
The tumor is no more than three (3) cm in size;
and
- Surgical resection or radiation treatment with curative intent is considered appropriate based on stage of disease (i.e., not stage one (1)) however, medical comorbidity renders the individual unfit for those interventions.
RFA for isolated peripheral non-small cell lung cancer not meeting the criteria as indicated in this policy is considered experimental/investigational, and is therefore, non-covered, because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
Malignant Non-Pulmonary Tumor(s) Metastatic to the Lung
RFA may be considered medically necessary to treat malignant non-pulmonary tumor(s) metastatic to the lung when
ALL
the following criteria are met:
-
The tumor is no more than three (3) cm in size;
and
-
In order to preserve lung function when surgical resection or radiation treatment is likely to substantially worsen pulmonary status
or
the individual is not considered a surgical candidate;
and
-
There is no evidence of extrapulmonary metastases
; and
-
The tumor is located at least one (1) cm from the trachea, main bronchi, esophagus, aorta, aortic arch branches, pulmonary artery and the heart;
and
- Tumors should be amenable to complete ablation.
Twelve months should elapse before a repeat ablation is considered.
RFA for malignant non-pulmonary tumors metastatic to the lung cancer not meeting the criteria as indicated in this policy is considered experimental/investigational, and is therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
Procedure Code
