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Clinical Policy Title: Radiofrequency ablation of tumors
Clinical Policy Number: 05.03.08
Effective Date: April 1, 2018
Initial Review Date: February 6, 2018
Most Recent Review Date: March 6, 2018
Next Review Date: March 2019
Related policies:
CP# 05.02.09 Radioembolization and chemoembolization for liver cancer and other indications
CP# 12.03.04 Radiofrequency ablation of uterine fibroids
ABOUT THIS POLICY: Select Health of South Carolina has developed clinical policies to assist with making coverage determinations. Select
Health of South Carolina’s clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of “medically necessary,” and the specific facts of the particular situation are considered by Select Health of South Carolina when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. Select Health of South Carolina’s clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. Select Health of South Carolina’s clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, Select Health of South Carolina will update its clinical policies as necessary. Select Health of South Carolina’s clinical policies are not guarantees of payment.
Coverage policy
Select Health of South Carolina considers the use of radiofrequency ablation to be clinically proven and,
therefore, medically necessary in members aged 18 years and older for treatment of tumors that are
accessible to the procedure and at least 1 cm from major organs or structures that could be injured by
thermal conduction, including:
Hepatocellular carcinoma confirmed by biopsy or imaging (National Comprehensive Care
Network [NCCN], 2017a; Interqual, 2016; American College of Radiology [ACR], 2015):
- Bridge therapy to maintain candidacy for liver transplantation.
- When a member is medically inoperable, ineligible for liver transplantation, or
refuses resection, and has either:
Barcelona Clinic Liver Cancer early-stage (defined as a single tumor < 5 cm at
its longest axis, or two or three tumors each ≤ 3 cm, Child-Pugh A-B, and
performance status 0) with no extrahepatic disease.
Barcelona Clinic Liver Cancer intermediate stage (defined as a single large
tumor or multinodular disease, preserved liver function, and no
extrahepatic spread or macrovascular invasion) and tumors have been
Policy contains:
Radiofrequency
ablation.
Neoplasms.
Osteoid osteomas.
Barrett’s esophagus.
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downsized to a single tumor ≤ 5 cm or two to three tumors each ≤ 3 cm
following transarterial therapy.
Liver metastases confirmed by biopsy or imaging when all of the following criteria are met
(NCCN, 2017a, b, c, f; ACR, 2015; Interqual, 2016):
- Tumors ≤ 5 cm.
- Ineligible for surgical resection.
- For members with colorectal cancer, metastases are confined to the liver.
- For members with neuroendocrine tumor involvement, persistent symptoms after
medical treatment with somatostatin analogs.
Renal cell carcinoma when all of the following criteria are met (NCCN, 2018; Interqual,
2017):
- Stage I (T1a). - Confirmed by biopsy. - Single tumor > 1 cm and ≤ 4 cm. - No metastasis.
Symptomatic osteolytic bone metastases in members who have failed, or are poor
candidates for, standard pain treatments such as radiation or opioids (Rosian, 2017;
Rosenthal, 2012; Warmuth, 2012).
Primary or secondary lung cancers (NCCN, 2018; National Institute for Health and Care
Excellence [NICE], 2010a):
- Early-stage, resectable (stage I-II, N0) non-small cell lung cancer in members who
are medically inoperable or refuse surgery (Bi, 2016; Sher, 2011).
- For members: who are not candidates for stereotactic ablative radiotherapy,
external beam radiation therapy, or sublobar resection; who have failed stereotactic
ablative radiotherapy; or for whom local control may not be the highest priority
(NCCN, 2018).
Primary therapy for:
Intestinal metaplasia (Barrett’s esophagus) (Almeida, 2016; NICE, 2014; NICE,
2010b).
Early-stage esophageal or esophagogastric cancer (pTis, pT1a, pTibN0) with or
without endoscopic resection (NCCN, 2017d).
After esophageal resection for residual or recurrent high-grade or low-grade esophageal
dysplasia (NCCN, 2017d; Evans, 2013).
Thyroid cancer for locoregional control when standard therapy (e.g., surgery or local
therapies) is contraindicated, has failed, or is refused (NCCN, 2017e; NICE, 2016).
Metastatic (synchronous stage IV) soft tissue sarcoma of the trunk, extremity, head, or neck
(NCCN, 2018c; Gronchi, 2016):
- Primary local therapy when confined to a single organ and limited tumor bulk.
- Palliative therapy for symptomatic disseminated disease.
Select Health of South Carolina considers the use of radiofrequency ablation to be clinically proven and,
therefore, medically necessary for treatment of osteoid osteomas that cannot be managed successfully
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with medical treatment, are accessible to the procedure, and at least 1 cm from major organs or
structures that could be injured by thermal conduction (Rosenthal, 2012; Warmuth, 2012).
Limitations:
The effectiveness of radiofrequency ablation for indications other than the ones listed above has not
been established. Radiofrequency ablation may be considered on a case-by-case basis for removal of
other primary or metastatic malignant neoplasms when either:
Removal of the neoplasm may be curative and the member is unable to tolerate or refuses
surgical resection or radiation therapy.
Palliative debulking or complete removal may relieve symptoms.
Relative contraindications include (NCCN, 2017a, b, c; Interqual, 2016):
Ablative margins measuring less than 1 cm (i.e., tumors should be located at least 1 cm from
critical structures or vessels to achieve complete tumor destruction), except in cases of
palliation or debulking.
More than three tumors per organ. However, the number of lesions should not be
considered an absolute contraindication to radiofrequency ablation if successful treatment
of all metastatic deposits can be accomplished.
Untreatable or unmanageable coagulopathy is an absolute contraindication to radiofrequency ablation.
Alternative covered services:
Standard of care specific to each tumor.
Background
Radiofrequency ablation applies heat using high-frequency alternating current via electrodes placed
within the tissue to induce tissue coagulation and cell death (Friedman, 2004). It is one of several types
of ablative therapies used to treat a wide range of cardiac, neurologic, vascular, and oncologic
conditions. The U.S. Food and Drug Administration (FDA) classifies radiofrequency ablation as an
electrosurgical, cutting, and coagulation device with 510(k) marketing submission requirements (FDA,
2017).
Radiofrequency ablation can be applied percutaneously, laparoscopically, or at open surgery. The choice
of technique will depend on: the patient’s condition; tumor size, number, location, and growth pattern;
and operator and local practice patterns. It may be performed in outpatient or inpatient settings under
general anesthesia, conscious sedation, or deep sedation (Friedman, 2004).
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Percutaneous radiofrequency ablation is a minimally invasive, repeatable procedure performed under
radiologic guidance. The percutaneous approach requires that tumors not lie adjacent to other organs
or vessels that could be injured by thermal conduction. Surgical approaches allow a more accurate
evaluation of disease in and around the organ and present less risk to adjacent structures. The open
approach allows for concurrent combination therapies, such as resection and placement of pumps for
regional chemotherapy (Friedman, 2004).
This policy will focus on radiofrequency ablation as treatment for tumors and pre-malignant conditions,
excluding treatment of uterine fibroids. See Clinical policy #12.03.04 Radiofrequency ablation of uterine
fibroids.
Searches
Select Health of South Carolina searched PubMed and the databases of:
UK National Health Services Centre for Reviews and Dissemination.
Agency for Healthcare Research and Quality’s National Guideline Clearinghouse and other
evidence-based practice centers.
The Centers for Medicare & Medicaid Services (CMS).
We conducted searches on January 8, 2018. Search terms were: "Catheter Ablation" (MeSH),
"Neoplasms" (MeSH), and the free text terms “radiofrequency ablation” and “RFA.”
We included:
Systematic reviews, which pool results from multiple studies to achieve larger sample sizes
and greater precision of effect estimation than in smaller primary studies. Systematic
reviews use predetermined transparent methods to minimize bias, effectively treating the
review as a scientific endeavor, and are thus rated highest in evidence-grading hierarchies.
Guidelines based on systematic reviews.
Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple
cost studies), reporting both costs and outcomes — sometimes referred to as efficiency
studies — which also rank near the top of evidence hierarchies.
Findings
Radiofrequency ablation was initially indicated as a treatment option for inoperable hepatic tumors. The
liver is a common site for metastasis from solid tumors, and many are unsuitable for surgical excision
because of their number, distribution, or the presence of extrahepatic spread (NCCN, 2017a).
Increasingly, radiofrequency ablation is becoming an attractive treatment option for locoregional
control, palliation, and, in some circumstances, cure of other solid tumors, including some operable
tumors for which well-established local or systemic treatment alternatives are available. For patients
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who present with significant surgical risks or who have significant competing comorbidities,
radiofrequency ablation balances potential cure, locoregional control, or palliation with treatment
toxicity and benefits common to any minimally invasive procedure (e.g., preserving normal organ tissue,
decreasing morbidity, decreasing length of hospitalization).
Existing evidence and clinical experience supports radiofrequency ablation as a safe procedure in the
hands of an experience specialist and effective in tumor destruction, which may be associated with
higher survival rates for some cancers. The most common complications include post-procedural pain,
fever, and burns. An absolute contraindication is uncontrolled coagulopathy. Other relative
contraindications primarily relate to tumor location and underlying organ function.
To be amenable to ablation, typically a 1 cm margin of tumor-free tissue is needed, except in cases of
palliation or debulking, and the tumor must be in an accessible location and away from major organs
and vessels. Currently, there is no standard tumor size or number of tumors appropriate for ablation;
however, studies have found improved outcomes when tumors 4 cm or smaller are treated (NCCN,
2017a, b, c; Interqual, 2016). Typically, choice of ablative technique is based on tumor size
(radiofrequency ablation is most effective for treating tumors < 3 cm at their longest axis) and location
and underlying organ function (NCCN, 2017a). Except for studies of osteoid osteoma, most studies
included patients older than 17 years.
Radiofrequency ablation is an established treatment alternative for the following hepatic indications
(NCCN, 2017a, b, c; ACR, 2015):
Early-stage hepatocellular carcinoma:
- Curative therapy for isolated tumors ≤ 3 cm (in select cases, up to 5 cm).
- Locoregional therapy in medically inoperable patients.
Neoadjuvant therapy as a bridge to transplant.
Isolated colorectal liver metastasis < 3 cm to 5 cm.
There is sufficient evidence to support radiofrequency ablation as a locoregional treatment option for
the following extrahepatic indications:
Early-stage renal cell carcinoma without metastasis (NCCN, 2018a).
Symptomatic osteolytic bone metastases in persons who have failed, or are poor candidates
for, standard treatments such as radiation or opioids (Rosian, 2017; Rosenthal, 2012;
Warmuth, 2012).
Osteoid osteomas that cannot be managed successfully with medical treatment (Rosenthal,
2012; Warmuth, 2012).
Primary or secondary lung cancers (NCCN, 2018b; NICE, 2010a):
- Early-stage, resectable (stage I-II, N0) non-small cell lung cancer in patients who are
medically inoperable or refuse surgery (Bi, 2016; Sher, 2011).
- For patients who are not candidates for stereotactic ablative radiotherapy, external
beam radiation therapy, or sublobar resection; who have failed stereotactic ablative
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radiotherapy; or for whom local control may not be the highest priority (NCCN,
2018b).
Primary therapy for intestinal metaplasia (Barrett’s esophagus) (NCCN, 2017d; Almeida,
2016; NICE, 2014; NICE, 2010b).
Residual or recurrent high-grade or low-grade esophageal dysplasia after esophageal
resection (NCCN, 2017d; Evans, 2013).
Thyroid cancer for locoregional control when standard therapy (e.g., surgery or local
therapies) is contraindicated, has failed, or is refused (NCCN, 2017e).
Metastatic (synchronous stage IV) soft tissue sarcoma of the trunk, extremity, head, or neck
(NCCN, 2018c):
Primary local therapy when confined to a single organ and limited tumor bulk.
Palliative therapy for symptomatic disseminated disease.
There is insufficient evidence to support the use of radiofrequency ablation for treatment of any other
malignant primary tumor or benign tumor, such as Morton’s neuroma (American Orthopaedic Foot and
Ankle Society, 2018; Valerio, 2017; Peek, 2016; Association of Extremity Nerve Surgeons, 2014; Fegrachi,
2014; Fischer, 2012b).
Policy updates:
None.
Summary of clinical evidence:
Citation Content, Methods, Recommendations
Rosian (2017) for the
Ludwig Boltzmann Institut
für Health Technology
Assessment (LBIHTA)
Radiofrequency ablation
for metastatic spinal
lesions
Key points:
Systematic review of four prospective single-arm studies and five retrospective single-arm
studies with at least 30 patients. Data on safety and efficacy were evaluated in 471 and
112 patients, respectively.
Significant improvement in pain relief (three prospective studies) and health-related
quality of life (two studies) after treatment with radiofrequency ablation and vertebroplasty.
No recurrence of vertebral metastases during follow-up (one study).
No major radiofrequency ablation-related complications were reported.
Adverse event rate (procedure-related or not procedure-related) = 18% (105/583
patients); most frequent radiofrequency ablation-related adverse events were increased
pain and numbness (7.8%, 6/77 patients); most frequent adverse event reported related
to vertebroplasty was cement extravasation (18.7%, 67/358 patients).
Valerio (2017)
New and established
technology in focal
ablation of the prostate
Key points:
Systematic review of 37 studies (3,230 total patients) of focal therapy using seven
sources of energy in single-arm retrospective and prospective development studies,
including one case series on radiofrequency.
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Citation Content, Methods, Recommendations
Focal therapy seems to have a minor impact on quality of life and genito-urinary function.
Oncological effectiveness is yet to be defined against standard of care.
Almeida (2016, update of
Xie, 2009) for the
Technology Assessment
Unit of McGill University
Health Centre
Radiofrequency ablation
for treatment of Barrett’s
esophagus
Key points:
Systematic review and cost analysis of two randomized controlled trials (RCTs), eight
single‐arm cohort studies, and one systematic review for high-grade dysplasia, and two
RCTs, one single-arm cohort study, and two meta-analyses for low-grade dysplasia.
Considered standard of care for treatment of high-grade dysplasia based on good-quality
evidence of effectiveness and safety in eliminating dysplastic tissue and higher morbidity
associated with esophagectomy.
More controversial for low-grade dysplasia based on lower quality evidence of diagnostic
accuracy, uncertainty surrounding the progression rates to cancer, and the spontaneous
reversion in some patients. Routine use not recommended but may be considered in
patients with risk factors suggestive of higher risk of progression to high-grade
dysplasia/cancer (e.g., multifocal, long segment, or persistent Barrett’s esophagus).
Bi (2016)
Comparison of the
effectiveness of
radiofrequency ablation
with stereotactic body
radiation therapy in
inoperable stage I non-
small cell lung cancer
Key points:
Systematic review and pooled analysis of 31 primarily case series of stereotactic body
radiation therapy (2,767 patients) and 13 studies of radiofrequency ablation (328
patients).
Local tumor control rates (95% confidence interval) at 1, 2, 3, and 5 years:
- Radiofrequency ablation = 77% (70% to 85%), 48% (37% to 58%), 55% (47% to
62%), and 42% (30% to 54%), respectively.
- Stereotactic body radiation therapy = 97% (96% to 98%), 92% (91% to 94%),
88% (86% to 90%), and 86% (85% to 88%) (P < .001).
Differences remained significant after correcting for stage IA and age (P < .001 at 1 year,
2 years, and 3 years; P = .04 at 5 years).
No statistically significant difference in overall survival between modalities (P > .05).
Most frequent complication of radiofrequency ablation was pneumothorax (31%) and of
stereotactic body radiation therapy was (grade ≥ 3) radiation pneumonitis (2%)
Chen (2016)
Radiofrequency ablation
for treatment of benign
thyroid nodules
Key points:
Systematic review and meta-analysis 20 single-arm studies comprising data from 1,090
patients with 1,406 benign thyroid nodules.
Overall quality: low with significant publication bias.
Radiofrequency ablation significantly decreased nodule volume at 1, 3, 6, 12, and the last
follow-up months compared to baseline, including a decline by cold and hot nodules.
Radiofrequency ablation decreased the largest diameter, symptom score, cosmetic score,
triiodothyronine level, and vascular scale, had no effect in free thyroxine, and increased
thyrotropin level.
Peek (2016)
Minimally invasive ablative
techniques in the
treatment of breast cancer
Key points:
Systematic review and meta-analysis of 63 studies, including 1,608 patients with breast
tumors treated with radiofrequency ablation, high-intensity focused ultrasound, and cryo-,
laser-, or microwave-ablation.
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Citation Content, Methods, Recommendations
Highest rate of complete ablation was achieved with radiofrequency ablation (87.1%,
491/564 patients) and microwave ablation (83.2%, 89/107 patients).
Microwave ablation had the highest rate of short-term complications (14.6%, 21/144
patients).
Overall recurrence rate = 4.2% (24/570 patients) and most often with laser ablation
(10.7%, 11/103 patients).
Radiofrequency ablation had the shortest treatment times (15.6 ± 5.6 min) and high-
intensity focused ultrasound the longest (101.5 ± 46.6 min).
Adequately powered and prospectively conducted cohort trials are needed to confirm
complete pathological ablation in all patients.
Fegrachi (2014)
Radiofrequency ablation
for unresectable locally
advanced pancreatic
cancer
Key points:
Systematic review of five non-comparative studies (158 total patients).
Overall quality: low with high risk of bias and heterogeneous study populations and
outcomes.
Median survival after radiofrequency ablation = three months to 33 months.
Procedure-related morbidity = 4% to 37%, overall mortality = 0% to 19%, overall morbidity
= 10% to 43%. Pooling of data was not done due to heterogeneous study populations and
outcomes.
Radiofrequency ablation appears safe when used with the correct temperature and at an
appropriate distance from vital structures, but multi-center RCTs are needed to determine
the true effect size of radiofrequency ablation and to minimize bias.
Fischer (2012a) for the
LBIHTA
Radiofrequency ablation
for the treatment of benign
and malignant nodules of
endocrine organs (thyroid
gland and adrenal gland)
Key points:
Systematic review of three case series of benign thyroid nodules, one case series of
thyroid cancer, and two case series of adrenal tumors.
Overall quality: very low.
Thyroid tumors: radiofrequency ablation is safe and improves tumor-related symptoms.
Adrenal tumors: radiofrequency ablation is safe and possibly improves aldosteronism and
reduces recurrence.
Higher-quality studies are needed to confirm these findings.
Fischer (2012b) for the
LBIHTA
Radiofrequency ablation
for the treatment of head
and neck cancer
Key points:
Systematic review identified one case series of 21 patients with various recurrent or
unresectable/inoperable head and neck cancer aged around 63 years. Follow up =
approximately 44 days; drop-out rate = 38%.
Marginal improvement in quality of life, median survival was four months, 45% with
serious complications, and 5% procedure-related mortality.
Rosenthal (2012)
Critical review and state of
the art in interventional
oncology: benign and
metastatic disease
involving bone
Key points:
Percutaneous radiofrequency ablation is an important treatment for both benign bone
tumors and palliation of metastases involving bone and soft-tissue sites beyond the liver
and lung.
Image-guided radiofrequency ablation is now the standard treatment for osteoid osteoma,
as the procedure can be performed with higher rates of technical success, decreased
morbidity, and lower cost than those with open surgery.
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Citation Content, Methods, Recommendations
Several ablation methods can effectively treat focal metastatic skeletal disease, primarily
with the goal of durable palliation of pain, particularly when conventional therapies,
including chemotherapy and external-beam radiation, have failed.
Warmuth (2012) for the
LBIHTA
Radiofrequency ablation of
bone tumors (osteoid-
osteoma and osseus
metastases)
Key points:
Systematic review of four prospective case series (175 total patients aged 15 years to 23
years) of radiofrequency ablation for osteoid osteomas with a maximum tumor size = 15
mm, and two prospective case series (79 total patients aged 58 years to 62 years) with
osseous metastases with a mean tumor size of 5 cm.
Osteoid osteomas: residual and recurrent symptoms (pain) in 5% to 26% and 0% to 8% of
patients, respectively. Procedure-associated morbidity varied from 0% to 26%.
Painful osseous metastases: statistically significant reduced pain and improved mood at
one and three months following radiofrequency ablation. The local recurrence rate was
42% after 6 months. Intervention-associated pain was observed in 11% to 75% of
patients, other adverse events were seen in 2% to 13% of patients.
Sher (2011)
Cost-effectiveness
analysis of stereotactic
body radiation therapy and
radiofrequency ablation for
medically inoperable,
early-stage non-small cell
lung cancer
Key points:
Markov model describes health states of 65-year-old men with medically inoperable non-
small cell lung cancer after treatment with three-dimensional conformal radiation therapy,
stereotactic body radiation therapy, and radiofrequency ablation. Patients were assumed
to receive supportive care after recurrence. Utility values, recurrence risks, and costs
were adapted from the literature, and sensitivity analyses performed.
Stereotactic body radiation therapy was the most cost-effective treatment over a wide
range of treatment and disease assumptions. On the basis of efficacy and cost,
stereotactic body radiation therapy should be the primary treatment approach for this
disease.
References
Professional society guidelines/other:
American College of Radiology ACR Appropriateness Criteria®:
Early-stage non–small-cell lung cancer. Date of origin: 2013. ACR website.
https://acsearch.acr.org/docs/3082798/Narrative/. Accessed January 9, 2018.
Radiologic management of hepatic malignancy. Date of origin: 2007. Last review date: 2015.
ACR website. https://acsearch.acr.org/docs/69379/Narrative. Accessed January 9, 2018.
American Orthopaedic Foot and Ankle Society. Morton's Neuroma. American Orthopaedic Foot and
Ankle Society website. http://www.aofas.org/PRC/conditions/Pages/Conditions/Mortons-
Neuroma.aspx. Accessed January 14, 2018.
Association of Extremity Nerve Surgeons. Denervation. Clinical Practice Guidelines. Edition 1. 2014.
Association of Extremity Nerve Surgeons website.
https://www.aens.us/images/aens/AENSGuidelinesFinal-12082014.pdf. Accessed January 14, 2018.
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Evans JA, Early DS, Chandraskhara V, et al. The role of endoscopy in the assessment and treatment of
esophageal cancer. Gastrointest Endosc. 2013; 77(3): 328-334. DOI: 10.1016/j.gie.2012.10.001.
Gronchi A, Guadagnolo BA, Erinjeri JP. Local Ablative Therapies to Metastatic Soft Tissue Sarcoma. Am
Soc Clin Oncol Educ Book. 2016; 35: e566-575. DOI: 10.14694/edbk_157450.
National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology. NCCN website.
www.nccn.org. Accessed January 9, 2018:
Colon cancer. Version 2.2017.(b)
Esophageal and esophagogastric junction cancers. Version 4.2017.(d)
Hepatobiliary cancers. Version 4.2017.(a)
Gastric cancer. Version 5.2017.(g)
Kidney cancer. Version 2.2018.(a)
Neuroendocrine tumors. Version 3.2017.(f)
Non-small cell lung cancer. Version 2.2018.(b)
Rectal cancer. Version 3.2017.(c)
Soft tissue sarcoma. Version 1.2018.(c)
Thyroid carcinoma. Version 2.2017.(e)
National Institute for Health and Care Excellence (NICE):
Endoscopic bipolar radiofrequency ablation for treating biliary obstruction caused by
cholangiocarcinoma or pancreatic adenocarcinoma. Interventional procedures guidance
[IPG464]. Published date: September 2013. NICE website.
https://www.nice.org.uk/guidance/ipg464. Accessed January 10, 2018.
Epithelial radiofrequency ablation for Barrett's oesophagus [IPG344]. Evidence-based
recommendations on epithelial radiofrequency ablation for treating Barrett's oesophagus.
Interventional procedures guidance. Published May 2010.
https://www.nice.org.uk/guidance/ipg344. Accessed January 10, 2018.(b)
Endoscopic radiofrequency ablation for Barrett's oesophagus with low‑grade dysplasia or
no dysplasia. Interventional procedures guidance [IPG496]. Published date: July 2014.
https://www.nice.org.uk/guidance/ipg496. Accessed January 10, 2018.
Percutaneous radiofrequency ablation for primary or secondary lung cancers. Interventional
procedures guidance [IPG372]. Published date: December 2010. NICE website.
https://www.nice.org.uk/guidance/ipg372. Accessed January 10, 2018.(a)
Radiofrequency ablation for symptomatic interdigital (Morton’s) neuroma [IPG539].
Evidence-based recommendations on radiofrequency ablation for symptomatic interdigital
(Morton’s) neuroma. Interventional procedures guidance. Published December 2015. NICE
website. https://www.nice.org.uk/guidance/ipg539. Accessed January 10, 2018.
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Ultrasound-guided percutaneous radiofrequency ablation for benign thyroid nodules.
Interventional procedures guidance [IPG562]. Published date: June 2016. NICE website.
https://www.nice.org.uk/guidance/ipg562. Accessed January 10, 2018.
Peer-reviewed references:
Bi N, Shedden K, Zheng X, Kong FS. Comparison of the Effectiveness of Radiofrequency Ablation With
Stereotactic Body Radiation Therapy in Inoperable Stage I Non-Small Cell Lung Cancer: A Systemic
Review and Pooled Analysis. Int J Radiat Oncol Biol Phys. 2016; 95(5): 1378-1390. DOI:
10.1016/j.ijrobp.2016.04.016.
Chen F, Tian G, Kong D, Zhong L, Jiang T. Radiofrequency ablation for treatment of benign thyroid
nodules: A PRISMA-compliant systematic review and meta-analysis of outcomes. Medicine (Baltimore).
2016; 95(34): e4659. DOI: 10.1097/md.0000000000004659.
FDA Product Classification database searched using product code GEI. FDA website.
https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPCD/classification.cfm. Accessed January 14,
2018.
Fegrachi S, Besselink MG, van Santvoort HC, van Hillegersberg R, Molenaar IQ. Radiofrequency ablation
for unresectable locally advanced pancreatic cancer: a systematic review. HPB (Oxford). 2014; 16(2):
119-123. DOI: 10.1111/hpb.12097.
Fischer S, Zechmeister-Koss I. Radiofrequency ablation for the treatment of benign and malignant
nodules of endocrine organs (thyroid gland and adrenal gland). [Radiofrequenzablation bei benignen
und malignen Veränderungen endokriner Organe (Schilddrüse und Nebenniere)]. Systematischer
Review. Decision Support Dokument Nr. 56; 2012. Wien: Ludwig Boltzmann Institut für Health
Technology Assessment (LBIHTA). 2012. LBIHTA website. http://eprints.hta.lbg.ac.at/960/1/DSD_56.pdf.
Accessed January 10, 2018.(a)
Fischer S, Zechmeister-Koss I. Radiofrequency ablation for the treatment of head and neck cancer.
[Radiofrequenzablation bei Kopf- und Halstumoren]. Systematischer Review. Decision Support
Dokument Nr. 55; 2012. Wien: Ludwig Boltzmann Institut für Health Technology Assessment. 2012.
LBIHTA website. http://eprints.hta.lbg.ac.at/959/1/DSD_55.pdf. Accessed January 9, 2018.(b)
Friedman M, Mikityansky I, Kam A, et al. Radiofrequency Ablation of Cancer. Cardiovasc Intervent Radiol.
2004; 27(5): 427-434. DOI: 10.1007/s00270-004-0062-0.
Interqual® criteria. 2016 Procedures Criteria. Radiofrequency ablation (RFA) or transarterial
embolization, (TACE), liver. McKesson Corporation. San Francisco, California.
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Interqual® criteria. 2017 Procedures Criteria. Radiofrequency ablation (RFA) or cryoblation, renal.
McKesson Corporation. San Francisco, California.
Peek MC, Ahmed M, Napoli A, et al. Minimally invasive ablative techniques in the treatment of breast
cancer: a systematic review and meta-analysis. Int J Hyperthermia. 2016: 1-12. DOI:
10.1080/02656736.2016.1230232.
Rosenthal D, Callstrom MR. Critical Review and State of the Art in Interventional Oncology: Benign and
Metastatic Disease Involving Bone. Radiology. 2012; 262(3): 765-780. DOI: 10.1148/radiol.11101384.
Sher DJ, Wee JO, Punglia RS. Cost-effectiveness analysis of stereotactic body radiotherapy and
radiofrequency ablation for medically inoperable, early-stage non-small cell lung cancer. Int J Radiat
Oncol Biol Phys. 2011; 81(5): e767-774. DOI: 10.1016/j.ijrobp.2010.10.074.
Valerio M, Cerantola Y, Eggener SE, et al. New and Established Technology in Focal Ablation of the
Prostate: A Systematic Review. Eur Urol. 2017; 71(1): 17-34. DOI: 10.1016/j.eururo.2016.08.044.
Warmuth M, Nachtnebel A. Radiofrequency ablation of bone tumors (Osteoid-osteoma and bone
metastases). [Radiofrequenzablation bei Knochentumoren (Osteoid-Osteom und Knochenmetastasen).
Systematischer Review. Decision Support Dokument Nr. 54; 2012. Wien: Ludwig Boltzmann Institut für
Health Technology Assessment. LBIHTA website. http://eprints.hta.lbg.ac.at/958/1/DSD_54.pdf.
Accessed January 10, 2018.
Xie X, McGregor M, Dendukuri N. Radiofrequency ablation for treatment of Barrett’s esophagus: A
systematic review and cost analysis. Montreal (Canada): Technology Assessment Unit (TAU) of the
McGill University Health Centre (MUHC); 2009. Report no. 49. 37 p. Available at:
http://www.mcgill.ca/tau/files/tau/BARRETTs_ESOPHAGUS_REPORT.pdf. Accessed January 12, 2018.
CMS National Coverage Determinations (NCDs):
No NCDs identified as of the writing of this policy.
A52928 Sources of Information and Basis for Decision Noncovered Services LCD. CMS website.
https://www.cms.gov/medicare-coverage-database/details/article-
details.aspx?articleId=52928&ver=15. Accessed January 14, 2018. Addresses cryoablation explicitly, but
only references articles about RFA.
Local Coverage Determinations (LCDs):
No LCDs identified as of the writing of this policy.
Commonly submitted codes
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Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is
not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and
bill accordingly.
CPT Code Description Comments
20982
Ablation therapy for reduction or eradication of 1 or more bone tumors (eg,
metastasis) including adjacent soft tissue when involved by tumor extension,
percutaneous, including imaging guidance when performed; radiofrequency
32998
Ablation therapy for reduction or eradication of one or more pulmonary
tumor(s) including pleura or chest wall when involved by tumor extension,
percutaneous, radiofrequency, unilateral
43270
Esophagogastroduodenoscopy, flexible, transoral; with ablation of tumor(s),
polyp(s), or other lesion(s) (includes pre-hyphen and post-hyphendilation and
guide wire passage, when performed)
44369
Small intestinal endoscopy, enteroscopy, beyond second portion of
duodenum, not including ileum; with ablation of tumor(s), polyp(s) or other
lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or
snare technique
47380 Ablation, open, of one or more liver tumor(s); radiofrequency
47381 Cryosurgical
47382 Ablation, one or more liver tumor(s), percutaneous, radiofrequency
50592 Ablation, 1 or more renal tumor(s), percutaneous, unilateral, radiofrequency
53850 Transurethral destruction of the prostate tissue; by microwave thermotherapy
53852 by radiofrequency thermotherapy
ICD-10 Code Description Comments
C16.0 - C18.9 Malignant neoplasm of stomach, small intestine, and colon [metastatic
gastrointestinal stromal tumors (GIST) with limited progression]
C34.00 - C34.92 Malignant neoplasm of bronchus and lung
C49.0 - C49.9
Malignant neoplasm of other connective and soft tissue of upper limb,
including shoulder, lower limb, including hip, and trunk unspecified [in
symptomatic persons with disseminated metastases]
C64.1 - C64.9 Malignant neoplasm of kidney, except renal pelvis
C78.00 - C78.02 Secondary malignant neoplasm of lung
D02.20 -D02.22 Carcinoma in situ bronchus and lung
D16.00 - D16.9 Benign neoplasm of bone and articular cartilage [osteoid osteoma] [not
covered for chondroblastoma]
N18.3 Chronic kidney disease, stage 3 (moderate)
N18.4 Chronic kidney disease, stage 4 (severe)
N18.5 Chronic kidney disease, stage 5
Q60.0 Renal agenesis, unilateral
Z90.5 Acquired absence of kidney
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HCPCS
Level II Code Description Comments
C1886 Cather, extravascular tissue ablation, any modality