Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone

This policy covers cryosurgical ablation of tumors in the kidney, lung, breast, pancreas, and bone — including sonographically visible, biopsy‑confirmed breast fibroadenomas <2.5 cm; localized RCC ≤4 cm for medically or surgically inoperable patients or when renal preservation is necessary; early‑stage non–small cell lung cancer in poor surgical candidates; and palliative ablation for airway obstruction or pain from bone metastases. Coverage is restricted to the specific clinical criteria (e.g., size limits, ultrasound visibility and histologic confirmation for breast lesions, treating‑physician documentation of inoperability or need for kidney preservation such as single kidney or GFR <60), uses outside the listed indications are investigational, and cryoablation is generally considered tumor‑control or palliative rather than curative with higher local recurrence than surgical resection.

"Cryosurgical ablation for breast fibroadenoma when the lesion is sonographically visible, histologically confirmed, and < 2."