Isolated Peripheral Non-Small Cell Lung Cancer
RFA may be considered medically necessary to treat an isolated peripheral non-small-cell lung cancer lesion that is no more than three (3) cm in size when ALL the following criteria are met:
- Surgical resection or radiation treatment with curative intent is considered appropriate based on stage of disease, however, medical comorbidity renders the individual unfit for those interventions; and
- Tumor is located at least one (1) cm from the trachea, main bronchi, esophagus, aorta, aortic arch branches, pulmonary artery and the heart.
RFA for any other isolated peripheral non-small cell lung cancer is considered experimental/investigational, and is therefore, non-covered due to the evidence is insufficient to determine the impact of the technology on health outcomes.
Malignant Non-Pulmonary Tumor(s) Metastatic to the Lung
RFA may be considered medically necessary to treat malignant nonpulmonary tumor(s) metastatic to the lung that are no more than three (3) cm in size when the following criteria are met:
- In order to preserve lung function when surgical resection or radiation treatment is likely to substantially worsen pulmonary status or the individual is not considered a surgical candidate; and
- There is no evidence of extrapulmonary metastases; and
- The tumor is located at least 1 cm from the trachea, main bronchi, esophagus, aorta, aortic arch branches, pulmonary artery and the heart; and
- No more than three (3) tumors per lung should be ablated; and
- Tumors should be amenable to complete ablation; and
- Twelve (12) months should elapse before a repeat ablation is considered.
RFA for any other malignant non-pulmonary tumors metastatic to the lung is considered experimental/investigational, and is therefore, non-covered due to the evidence is insufficient to determine the impact of the technology on health outcomes.
Procedure Codes