Magnetic Resonance Imaging (MRI)-Guided Focused Ultrasound Surgery (MRgFUS)

Policy ID: S-186-016

Section: Surgery

Effective Date: July 01, 2019

Revised Date: January 09, 2023

Revision Effective Date: March 04, 2024

Last Reviewed: January 16, 2024

Applies To: Commercial and Medicaid Expansion

Description

Magnetic Resonance Imaging (MRI)-Guided Focused Ultrasound Surgery (MRgFUS) is a non-invasive treatment that combines two (2) technologies, focused ultrasound (US) and MRI. The treatment is also called HIFU, which stands for High Intensity Focused Ultrasound.

Criteria

Magnetic resonance imaging (MRI) - guided focused ultrasound surgery (MRgFUS) may be considered medically necessary for:

Pain palliation in adult individuals with metastatic bone cancer who failed or are not candidates for radiotherapy; or
Treatment of essential tremors.

MRgFUS not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

0398T

MRgFUS is considered experimental/investigational for ALL other indications, including but not limited to:

Uterine fibroids
Breast tumors
Brain tumors
Prostate tumors
Chronic neuropathic pain

Procedure Codes

0071T

0072T

Outpatient HCPCS (C Codes)

C9734

Diagnosis Codes

C79.51

G25.0

G25.89

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-19-2021 Coding Update -

Added diagnosis codes G25.0 and G25.89.

Internal Medical Policy Committee 1-20-2022 Coding Update-Effective January 01, 2022

Added procedure codes: 61736 and 61737
Removed procedure code: 0398T

Internal Medical Policy Committee 1-26-2023 - Revision - Effective March 06, 2023

Updated with clarifying language
Removed procedure codes 61736 and 61737

Internal Medical Policy Committee 1-16-2024 Annual review - no changes in criteria

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.

Policy ID: S-186-015

Section: Surgery

Effective Date: July 01, 2019

Revised Date: December 08, 2021

Revision Effective Date: January 01, 2022

Last Reviewed: January 20, 2022

Archived Date: March 05, 2023

Applies To: Commercial and Medicaid Expansion

Description

Magnetic Resonance Imaging (MRI)-Guided Focused Ultrasound Surgery (MRgFUS) is a non-invasive treatment that combines 2 technologies, focused ultrasound (US) and MRI. The treatment is also called HIFU, which stands for High Intensity Focused Ultrasound.

Criteria

Magnetic resonance imaging (MRI) - guided focused ultrasound surgery (MRgFUS) may be considered medically necessary for pain palliation in adult individuals with metastatic bone cancer who failed or are not candidates for radiotherapy.

MRgFUS may be considered medically necessary for treatment of medicine-refractory essential tremors.

MRgFUS is considered experimental/investigational for ALL other indications, including but not limited to:

Uterine fibroids
Breast tumors
Brain tumors
Prostate tumors
Chronic neuropathic pain

Procedure Codes

0071T

0072T

61736

61737

Outpatient HCPCS (C Codes)

C9734

Diagnosis Codes

C79.51

G25.0

G25.89

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-19-2021 Coding Update - Added diagnosis codes G25.0 and G25.89.

Internal Medical Policy Committee 1-20-2022 Coding Update-Effective January 01, 2022

Added procedure codes: 61736 and 61737
Removed procedure code: 0398T

Links

References (PDF)

Disclaimer

Our Partners in Health:
Members
Employers
Producers

Fargo (Headquarters)
4510 13th Ave. S.
Fargo, N.D., 58121

Medical Policies Quick Search