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Cryosurgical Ablation and Radiofrequency Ablation of Renal Tumors

Section: Surgery
Effective Date: July 01, 2018
Revised Date: May 14, 2018
Last Reviewed: July 16, 2019

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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