CG-SURG-61 Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the Liver

This policy addresses the use of cryosurgical, radiofrequency, microwave, or laser ablation to treat solid tumors outside the liver. Coverage is provided for whole-gland cryosurgical ablation of the prostate for prostate cancer, and for thermal ablation (radiofrequency, cryoablation, or microwave) of NSCLC when curative surgery or radiation would otherwise be appropriate but the patient is medically unfit, each tumor is ≤3.0 cm, and all tumors are ≥1 cm from the trachea, main bronchi, esophagus, aorta and its arch branches, pulmonary artery, and heart. Not covered: focal prostate cryoablation, laser ablation/laser interstitial thermal therapy, and any thermal ablation of tumors outside the liver when these criteria are not met or for all other indications.

"Whole-gland cryosurgical ablation of the prostate is consideredmedically necessaryas a treatment of prostate cancer."