SURG.00165 Histotripsy

This policy addresses histotripsy, a non-thermal ultrasound ablation technique for destroying liver tumors. It is medically necessary only for primary or metastatic liver tumors when other treatments are not available or appropriate—evidenced by at least one of the following: unresponsive to prior therapies, relapse after prior therapies, intolerance to available therapies, or thermal ablation is not viable due to tumor location. All other uses, or when these criteria are not met, are considered investigational and not medically necessary.

"Histotripsy is consideredmedically necessarywhenallof the following criteria (A, B, C, and D) are met:"

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