CG-MED-81 Ultrasound Ablation for Oncologic Indications

This policy addresses the use of high-intensity focused ultrasound (HIFU) for oncologic indications. HIFU is covered only for pain palliation of localized metastatic bone pain when all are met: age ≥18, metastases ≥1 cm from skin and major nerve bundles, low fracture risk (e.g., Mirel’s score ≤7), and no need for surgical stabilization or presence of significant comorbidities. HIFU is not covered when these criteria are unmet or for any other indications (including prostate cancer), and transurethral ultrasound ablation (TULSA) is not covered for any indication, including prostate cancer.

"The use of high intensity focused ultrasound (HIFU) is consideredmedically necessaryfor pain palliation in individuals with localized metastatic bone pain whenallthe following criteria are met:"

Sign up to see full coverage criteria, indications, and limitations.