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

Section: Surgery
Effective Date: July 01, 2019
Revised Date: June 14, 2019

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 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

Procedure Codes

0071T  0072T  0398T

Outpatient HCPCS (C Codes)

C9734

Diagnosis Codes

C79.51 G25.0

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