SURG.00126 Irreversible Electroporation

This policy addresses irreversible electroporation (IRE) ablation of soft tissue or solid organs (e.g., liver, pancreas, prostate), including use of the NanoKnife system. Anthem considers IRE investigational and not medically necessary for these uses; therefore, it is not covered. There are no covered indications, and related claims (e.g., CPT/HCPCS 00126, 47384, 55877, 93799, S0748) are subject to denial as investigational.

"Irreversible electroporation is consideredinvestigational and not medically necessaryfor ablation of soft tissue orof solid organs including, but not limited to, the liver, pancreas, and prostate."

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