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

Policy ID: S-186-014

Section: Surgery

Effective Date: July 01, 2019

Revised Date: December 29, 2020

Revision Effective Date: January 01, 2021

Last Reviewed: January 19, 2021

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

0398T

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.

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: July 01, 2019

Revised Date: June 14, 2019

Archived Date: December 31, 2020

Description

Criteria

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

Magnetic resonance imaging (MRI)-guided focused ultrasound surgery (MRgFUS) may be considered medically necessary for treatment of medicine-refractory essential tremors.

Magnetic resonance imaging-guided high intensity focused ultrasound ablation is considered experimental/investigational for ALL other indications, including but not limited to:

Uterine fibroids
Breast tumors
Brain tumors
Prostate tumors
Chronic neuropathic pain