C9751 — Bronchoscopy, rigid or flexible, transbronchial ablation of lesion(s) by microwave energy, including fluoroscopic guidance, when performed, with computed tomography acquisition(s) and 3-d rendering, computer-assisted, image-guided navigation, and endobronchial ultrasound (ebus) guided transtracheal and/or transbronchial sampling (e.g., aspiration[s]/biopsy[ies]) and all mediastinal and/or hilar lymph node stations or structures and therapeutic intervention(s)
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- None specified in this Clinical Policy Bulletin. (The policy does not list required medical records, test results, or other documentation requirements.)
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.