A5059
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- Benign cytology ononefine needle or core biopsy;and
- Whole-gland cryosurgical ablation of the prostate is consideredmedically necessaryas a treatment of prostate cancer.
- Thermal ablation (radiofrequency ablation, cryoablation or microwave ablation) of NSCLC is consideredmedically necessarywhen all of the following criteria are met:
- Surgical or radiation treatment with curative intent is considered appropriate based on stage of disease, however medical co-morbidity renders the individual unfit for those interventions;and
- No tumor has a maximum diameter of greater than 3.0 cm;and
- Tumors are located at least 1 cm from the trachea, main bronchi, esophagus, aorta, aortic arch branches, pulmonary artery and the heart.
1 Active Policy
ANTHEM-CG-SURG-61 — CG-SURG-61 Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the Liver
Related Codes
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