00165
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- Targeted tumor(s) diameter 3 centimeters (cm) or less;and
- Three or fewer tumors will be treated.
- Histotripsy is consideredmedically necessarywhenallof the following criteria (A, B, C, and D) are met:
- Treatment is intended for destruction of liver tumors (primary or metastatic);and
- There is a lack of other available therapies (locoregional therapies, chemotherapy, immunotherapy, targeted therapies) as evidenced byat least oneof the following:Unresponsive to other therapies;orRelapse following other therapies;orIntolerant to other available therapies;orThermal ablation is not viable due to tumor location (for example, proximity to vital structures or centrally located);and
- Unresponsive to other therapies;or
1 Active Policy
ANTHEM-SURG.00165 — SURG.00165 Histotripsy
Related Codes
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