Cryosurgical Ablation and Radiofrequency Ablation of Renal Tumors

Policy ID: S-158-018

Section: Surgery

Effective Date: July 01, 2018

Revised Date: May 14, 2019

Last Reviewed: July 22, 2020

Description

Cryosurgical ablation of the kidney (also called cryosurgery, cryotherapy, or cryodestruction) is the use of extreme cold to destroy cancer cells while preserving the surrounding healthy tissue.

Radiofrequency ablation (RFA) is a type of treatment for malignant renal tumors. This technique uses heat to destroy cancerous cells.

Criteria

Cryosurgical ablation of renal cell carcinoma may be considered medically necessary to treat localized renal cell carcinoma that is no more than 4 cm in size when EITHER of the following criteria is met:

Prevention of kidney function is necessary:
- Individual has 1 (one) kidney; or
- Renal insufficiency defined by a glomerular filtration rate of less than 60 mL/min/m²; and
- Standard surgical approach (i.e. resection of renal tissue) is likely to worsen existing kidney function substantially; or
The individual is not considered a surgical candidate.

Cryosurgical ablation is considered not medically necessary for renal cell carcinoma that does not meet the above criteria,

Procedure Codes

50250

50542

50593

Radiofrequency ablation of renal cell carcinoma may be considered medically necessary to treat localized small renal cell carcinoma that is no more than 4 cm in size when EITHER of the following criteria is met:

Preservation of kidney function is necessary:
- The individual is not considered a surgical candidate.
- Renal insufficiency defined by a glomerular filtration rate of less than 60 ml/min/m² ; and
- Standard surgical approach (i.e. resection of renal tissue) is likely to substantially worsen existing kidney function; or
The individual is not considered a surgical candidate.

Radiofrequency ablation is considered not medically necessary for renal cell carcinoma that does not meet the above criteria.

Procedure Codes

50542

50592

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes 50250, 50542, 50592, 50593

C64.1	C64.2	C64.9	C65.1	C65.2	C65.9	D49.511
D49.512	D49.519

Professional Statements and Societal Positions Guidelines

National Comprehensive Cancer Network - 2019

The NCCN guidelines (v.2.2020) for renal cancer indicate that “[t]hermal ablation (e.g., cryosurgery, radiofrequency ablation) is an option for the management of individuals with clinical stage T1 renal lesions. Thermal ablation is an option for masses <3 cm, but it may also be an option for larger masses in select individuals. Ablation in masses >3 cm is associated with higher rates of local recurrence/persistence and complications.

ND Committee Review

Internal Medical Policy Committee 3-16-2020 Annual Review-no changes

Internal Medical Policy Committee 7-22-2020 No changes

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving and the Company reserves the right to review and update medical policy periodically.

Section: Surgery

Effective Date: June 30, 2018

Revised Date: May 14, 2019

Last Reviewed: March 16, 2020

Archived Date: August 07, 2020

Description

Cryosurgical ablation of the kidney (also called cryosurgery, cryotherapy, or cryodestruction) is the use of extreme cold to destroy cancer cells while preserving the surrounding healthy tissue.

Radiofrequency ablation (RFA) is a type of treatment for malignant renal tumors. This technique uses heat to destroy cancerous cells.

Criteria

Cryosurgical ablation of renal cell carcinoma may be considered medically necessary for select patients with small renal cell carcinoma less than or equal to 4cm when ANY ONE of the following criteria is met:

Individuals who are considered high-risk surgical candidates; or
Individuals with renal insufficiency, as defined by a glomerular filtration rate of less than or equal to 60 ml/min/m2; or
Individuals with a solitary kidney.

Cryosurgical ablation is considered not medically necessary for renal cell carcinoma that does not meet the above criteria.

Procedure Codes

50250

50542

50593

Radiofrequency ablation of renal cell carcinoma may be considered medically necessary for patients with small renal tumors less than or equal to 4cm when ANY ONE of the following criteria is met:

Preservation of kidney function is necessary (i.e., the patient has 1 kidney or renal insufficiency defined by a glomerular filtration rate of less than 60 ml/min/m2) and standard surgical approach (i.e., resection of renal tissue) is likely to substantially worsen kidney function; or
The patient is not considered a surgical candidate.

Radiofrequency ablation is considered not medically necessary for renal cell carcinoma that does not meet the above criteria.

Procedure Codes

50542

50592

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes 50250, 50542, 50592 and 50593

C64.1	C64.2	C64.9	C65.1	C65.2	C65.9	D49.511
D49.512	D49.519

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