Description

In radiofrequency ablation (RFA), heat is projected into a tumor by a high-frequency, alternating current that flows from electrodes. The cells killed by RFA are gradually replaced by fibrosis and scar tissue. RFA can be performed percutaneously, laparoscopically, or as an open procedure.

Criteria

Osteolytic Bone Pain

RFA may be considered medically necessary to palliate pain in individuals with osteolytic bone metastases who have failed or are poor candidates for standard treatments such as radiation or opioids.

RFA as initial treatment for painful bony metastases is considered experimental/investigational, and therefore, non- covered. The evidence is insufficient to determine the impact of the technology on health outcomes.

Osteoid Osteomas

RFA may be considered medically necessary to treat osteoid osteomas that cannot be managed successfully with medical treatment.

RFA for osteoid osteomas that can be managed with medical treatment is considered experimental/investigational, and therefore, non-covered.  The evidence is insufficient to determine the impact of the technology on health outcomes.

Procedure Codes

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

RFA is considered experimental/investigational and therefore non-covered as a technique for ablation of: 

• Breast tumors;
• Lung cancer not meeting the criteria above;
• Osteoid osteomas that can be managed with medical treatment;
• Painful bony metastases as initial treatment; and
• All other tumors outside the liver including, but not limited to:
  • The head and neck
  • Thyroid
  • Ovary
  • Pelvic/abdominal metastases of unspecified origin.
    

The evidence is insufficient to determine the impact of the technology on health outcomes.

Procedure Codes

Diagnosis Codes

Diagnosis Codes for 20982 and 32998

Professional Statements and Societal Positions Guidelines

NA