58353
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
3.51
Facility
$203.75
Non-Facility
$890.80
Documentation Required
- No discrete 'Documentation Requirements' section is provided in this excerpt; however the policy implies that clinical documentation must support the specific selection criteria attached to each covered indication (examples below).
- For renal mass cryoablation: documentation of tumor size (≤4 cm) and documentation that patient meets at least one criterion: high-risk surgical candidate; renal insufficiency with documented GFR ≤ 60 ml/min/1.73 m2; or solitary kidney
- For adrenal gland metastases: documentation of adrenal lesion size (≤4 cm) (and typically documentation of metastatic disease and rationale for percutaneous ablation vs. surgery)
- For pulmonary metastatic lesions: documentation that member is not a surgical candidate and that there are ≤ 6 lesions each < 4 cm in diameter
Key Coverage Criteria
- C79.49 Secondary malignant neoplasm of other parts of nervous system
- C79.51 Secondary malignant neoplasm of bone
- C79.70 - C79.72 Secondary malignant neoplasm of adrenal gland
- C79.82 Secondary malignant neoplasm of genital organs [prostate]
- D02.20 - D02.22 Carcinoma in situ of bronchus and lung
- Cryoablation for locally recurrent or metastatic bone and soft tissue tumors
9 Active Policies
AMBETTER-CP.MP.106 — Endometrial Ablation
AETNA-CPB-0512 — Premenstrual Syndrome and Premenstrual Dysphoric Disorder
CIGNA-0013 — Endometrial Ablation - (0013)
AETNA-CPB-0091 — Endometrial Ablation
AETNA-CPB-0100 — Cryoablation
Related Codes
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