Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Radiofrequency Ablation and Cryosurgical Ablation of Lung Tumors

Policy #:11.00.16g

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

MEDICALLY NECESSARY

RADIOFREQUENCY ABLATION
Radiofrequency ablation (RFA) is considered medically necessary and, therefore, covered for the treatment of either of the following types of small (less than or equal to 3 cm) pulmonary lesions:
  • When the intent for treatment is curative; however, the individual has a primary malignant stage I lung tumor and is not a candidate for surgical resection.
    • A comprehensive evaluation by a thoracic surgeon is required to evaluate pulmonary function, comorbidities, and other factors to determine if the individual is declared to be inoperable for surgical resection, and is a candidate for RFA.
  • Slow-growing metastases restricted to the lungs in an individual who is not a candidate for surgical resection or in whom resection, external beam irradiation, and chemotherapy have failed.
    • A comprehensive evaluation by a thoracic surgeon is required to evaluate pulmonary function, comorbidities, and other factors to determine if the individual is declared to be inoperable for surgical resection, and is a candidate for RFA.

CRYOSURGICAL ABLATION
Cryosurgical ablation is considered medically necessary and, therefore, covered for the treatment lung cancer when either of the following criteria is met:
  • The individual has early-stage non-small cell lung cancer and is a poor surgical candidate
    • A comprehensive evaluation by a thoracic surgeon is required to evaluate pulmonary function, comorbidities, and other factors to determine if the individual is declared to be a poor candidate for surgical resection, and is a candidate for cryosurgical ablation.
  • The individual requires palliation for a central airway obstructing lesion

EXPERIMENTAL/INVESTIGATIONAL

All other uses for RFA and cryosurgical ablation of lung tumors are considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of these services cannot be established by review of the available peer-reviewed published literature.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, radiofrequency ablation (RFA) and cryosurgical ablation of lung tumors are covered under the medical benefits of the Company’s products when the medical necessity criteria listed in the medical policy are met.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

The FDA issued a Public Health Notification entitled Radiofrequency Ablation of Lung Tumors, Clarification of Regulatory Status on September 24, 2008. This notification concerns the regulatory status of RFA devices that are used to treat lung tumors, the regulatory basis for the FDA's clearance of these devices for the indication of general soft tissue ablation, and the public health concerns related to the specific use of RFA to treat lung tumors.

Description

Primary lung cancer is the second most frequent malignancy for men and women and the leading cause of cancer death in the United States. Primary lung tumor types include small-cell lung cancer (SCLC) and non-small-cell lung cancer (NSCLC). Additionally, the lungs are a frequent site for metastases of other solid tumors.

Surgical resection is the most effective method for treating NSCLC and is considered the gold standard for early-stage NSCLC. Unfortunately, only 20 percent of individuals who present with pulmonary malignancies are surgical candidates, due to large tumor mass, end-stage disease, or various comorbidities. Alternatives to surgery, including radiotherapy and chemotherapy, produce substantial increases in survival, but only in small subsets of highly selected cases. Survival rates for unresectable primary pulmonary neoplasms are less than one year for individuals who receive either chemotherapy or radiation therapy. The survival rates do not greatly improve with combined therapy. In addition, there are risks associated with radiation therapy, such as injury to surrounding tissues and radiation pneumonitis.

RADIOFREQUENCY ABLATION

Radiofrequency ablation (RFA) involves placement of an electrode into tumor tissue under the guidance of ultrasound or computed tomography (CT). RFA uses a high-frequency alternating current similar to microwave heating to induce coagulation, necrosis, and tumor cell death within the targeted area. RFA systems include three components: a radiofrequency generator, needle electrodes, and grounding pads. RFA may be performed percutaneously, laparoscopically, or during open surgery.

The percutaneous approach of RFA is the least invasive, with fewer complications, which makes it an option for individuals who are unable to tolerate open surgery. Although pneumothorax is a common complication, fewer than 20 percent of individuals undergoing percutaneous RFA require treatment with needle aspiration or chest tube placement. The procedure can be performed in an outpatient setting with conscious sedation, or it can be performed under general anesthesia with a one- to two-day hospital stay. In general, the procedure results in lower morbidity and an improved quality of life for individuals who have few treatment options. Compared with surgery, RFA spares normal lung tissue and causes less impairment of pulmonary function. Moreover, the procedure can be repeated in the event of incomplete ablation or in cases of pulmonary recurrence.

At this time, no randomized controlled trials have been reported that directly compare RFA with radiotherapy or chemotherapy for the treatment of unresectable lung tumors. Few of the current RFA studies report histologic proof after treatment. Some, but not all, RFA studies report survival or progression-free survival in individuals who have received RFA treatment. When survival rates are reported, they compare favorably with or surpass those achieved by chemotherapy and radiation. However, there is great variability in the duration of follow-up after treatment. Unlike radiation or chemotherapy, RFA requires only one or two sessions, and side effects are minimal.

CRYOABLATION

Cryoablation involves freezing of target tissues; this is most often performed by inserting a coolant-carrying probe into the tumor. Cryosurgery may be performed as an open surgical technique or as a closed procedure under laparoscopic or ultrasound guidance.

EARLY-STAGE NON-SMALL CELL LUNG CANCER
Surgical resection is the preferred local treatment modality for early-stage lung tumors. Individuals with early-stage lung cancer who are not surgical candidates may be candidates for radiotherapy with curative intent. Cryoablation is being investigated in individuals who are medically inoperable, with small primary lung cancers or lung metastases. Individuals with more advanced local disease or metastatic disease may undergo chemotherapy with radiation following resection. Treatment is rarely curative; rather, it seeks to retard tumor growth or palliate symptoms.

The ECLIPSE trial (de Baere 2015) is a prospective, multicenter trial of cryoablation for metastatic disease in the lungs. The trial enrolled 40 participants with 60 metastatic lung lesions who were treated with cryoablation and had a least 12 months follow-up. Outcomes included survival, local tumor control, quality of life, and complications. Local tumor control was achieved in 94.2 percent of treated lesions, and one-year survival was 97.5 percent. There were no significant changes in quality of life over the 12-month study. The most common adverse advent was pneumothorax requiring chest tube insertion in 18.8 percent.

In 2015, Moore reported a retrospective case review of 45 individuals (47 tumors) managed with cryoablation during a five year period 2006-2011. The individuals were all biopsy proven early stage (T1a and T1b) primary lung tumors and had been assessed by a tumor board to be medically inoperable. Lesions were as small as 5 mm but the average was 1.9 cm (0.5-3 cm range). Cryoablation procedures were performed under general anesthesia. The primary endpoint was completion of freeze-thaw cycle. Mean follow-up was 51 months ±10 with observed five-year survival rate of 67.8 percent ± 15.3, cancer-specific survival rate at five years of 56.6 percent ± 16.5, and five-year progression-free survival rate of 87.9 percent ± 9. There were seven (14.8 percent) local recurrences; two had device failure and retreatment and another had retreatment for a recurrence at one year after initial treatment. The ablation zone was less than 5 mm outside the margin of the tumor in five of the 47 treatments and four of these five had local recurrences. Complications primarily included 19 individuals (40 percent) with hemoptysis, two of which required bronchoscopy, and 24 cases (51 percent) of pneumothorax, one of which required surgical chest tube with prolonged placement and mechanical sclerosis. These three (6.4 percent) individuals were considered major complications but 30-day mortality was zero. The authors propose that cryoablation is associated with a good overall long-term survival with minimally significant complications. Cryoablation is a potentially curative, viable therapeutic option for individuals with stage I NSCLC who are deemed medically inoperable.

National Comprehensive Cancer Network (NCCN) Guidelines (v.2.2018) indicate for non-small cell lung cancer state that resection is the preferred local treatment modality, and other modalities include cryotherapy.

The evidence on cryosurgery for lung cancer consists of studies that use cryosurgery for inoperable or metastatic disease. The available studies are small cohort studies and nonrandomized studies with relatively short-term follow-up. There is lack of high-quality comparative studies to determine the efficacy and comparative effectiveness of cryoablation. Despite the weaknesses in the published clinical evidence, contextual factors contributing to its support include the lack of treatment alternatives and the potential for reduced harm compared to surgery.

OBSTRUCTIVE ENDOBRONCHIAL CANCER
Lung cancer is often diagnosed when it is at an advanced stage, and half of new diagnoses involve the central airways. Malignant airway obstruction causes dyspnea, cough, hemoptysis, and (as the tumor progresses) life-threatening suffocation. Treatment modalities such as external beam radiation and chemotherapy may lead to complications (e.g., endobronchial inflammation and swelling) that further compromise the airways.

Therapeutic bronchoscopic cryotherapy is an option that palliates symptoms caused by malignant airway obstruction and is now being provided more frequently in large medical centers in the United States. A cryosurgical probe, which is inserted into tumor tissue, causes rapid freeze and thaw cycles, resulting in tumor necrosis. Although it has been suggested that a drawback to the procedure is the need to return to the lesion to remove the necrotized material, studies have shown that, in most cases, individuals are able to expectorate it.

A large study found that 86 percent of individuals with advanced disease and respiratory manifestations associated with obstructive endobronchial cancer improved in one or more symptoms and quality-of-life scores when treated with endobronchial cryotherapy. Cryosurgery uses a rigid or flexible bronchoscope. General anesthesia is commonly required with the rigid bronchoscope, while local anesthesia may be used with the flexible bronchoscope. According to experts, the procedure is straightforward and safe; neither airway wall hemorrhage nor other major hemorrhage has been reported. Cryoablation is considered safe and efficacious in the treatment of obstructing bronchial tumors. However, cryosurgery for the treatment of lung tumors is in need of additional trials.

The National Institute for Health and Clinical Excellence (NICE) published guidance on the safety and efficacy of cryosurgery for malignant endobronchial obstruction. Noting that obstruction of the major airways can lead to gradual asphyxiation, the group found adequate evidence to support the use of the procedure as a palliative measure to control symptoms. It was noted that, because immediate relief is not provided, cryosurgery is not suitable for treatment of acute respiratory distress.
References


Akeboshi M, Yamakado K, Nakatsuka A, et al. Percutaneous radiofrequency ablation of lung neoplasms: initial therapeutic response. J Vasc Interv Radiol. 2004;15(5):463-470.

Ambrogi MC, Fanucchi O, Cioni R, et al. Long-term results of radiofrequency ablation treatment of stage I non-small cell lung cancer: a prospective intention-to-treat study. J Thorac Oncol. 2011;6(12):2044-2051.

Ambrogi MC, Lucchi M, Dini P, et al. Percutaneous radiofrequency ablation of lung tumours: results in the mid-term. Eur J Cardiothorac Surg. 2006;30(1):177-183.

American Cancer Society. Cancer Facts & Figures 2018. Atlanta: American Cancer Society; 2018. Available at: https://www.cancer.org/latest-news/facts-and-figures-2018-rate-of-deaths-from-cancer-continues-decline.html. Accessed January 19, 2018.

American College of Radiology (ACR). Radiofrequency ablation helpful improves lung cancer survival. March 29, 2007.

Asimakopoulos G, Beeson J, Evans J, Maiwand MO. Cryosurgery for malignant endobronchial tumors: analysis of outcome. Chest. 2005;127(6):2007-2014.

Beeson J. Palliation of tracheobronchial carcinoma: the role of cryosurgery. J Perioper Pract. 2007;1(7):332-339.

Beland M, Mueller PR, Gervais DA. Thermal ablation in interventional oncology. Semin Roentgenol. 2007;42(3):175-190.

Beland MD, Wasser EJ, Mayo-Smith WW, et al. Primary non-small cell lung cancer: review of frequency, location, and time of recurrence after radiofrequency ablation. Radiology. 2010;254(1):301-307.

Belfiore G, Moggio G, Tedeschi E, et al. CT-guided radiofrequency ablation: a potential complementary therapy for patients with unresectable primary lung cancer – a preliminary report of 33 patients. AJR Am J Roentgenol. 2004;183(4):1003-1011.

Bilal H, Mahmood S, Rajashanker B, et al. Is radiofrequency ablation more effective than stereotactic ablative radiotherapy in patients with early stage medically inoperable non-small cell lung cancer? Interact Cardiovasc Thorac Surg. 2012;15(2):258-265.

Boyar M, Raftopoulos H. Supportive care in lung cancer. Hematol Oncol Clin N Am. 2005;19(2):369-387.

Chan VO, McDermott S, Malone DE, et al. Percutaneous radiofrequency ablation of lung tumors: evaluation of the literature using evidence-based techniques. J Thorac Imaging. 2011;26(1):18-26.

Choe YH, Kim SR, Lee KS, et al. The use of PTC and RFA as treatment alternatives with low procedural morbidity in non-small cell lung cancer. Eur J Cancer. 2009;45(10):1773-1779.

Chua TC, Sarkar A, Saxena A, et al. Long-term outcome of image-guided percutaneous radiofrequency ablation of lung metastases: an open-labeled prospective trial of 148 patients. Ann Oncol. 2010;21(10):2017-2022.

Chua TC, Thornbury K, Saxena A, et al. Radiofrequency ablation as an adjunct to systemic chemotherapy for colorectal pulmonary metastases. Cancer. 2010;116(9):2106-2114.

Colt HG. Bronchoscopic cryotechniques in adults. 04/07/2017. Up to Date. [UpToDate Web site]. Available at: http://www.uptodate.com/home/index.html [via subscription only]. Accessed January 19, 2018.

de Bačre T, Palussičre J, Aupčrin A, et al. Midterm local efficacy and survival after radiofrequency ablation of lung tumors with minimum follow-up of 1 year: prospective evaluation. Radiology. 2006;240(2):587-596.

de Baere T, Tselikas L, Woodrum D, et al. Evaluating cryoablation of metastatic lung tumors in patients--safety and efficacy: the ECLIPSE Trial--interim analysis at 1 year. J Thorac Oncol. 2015;10(10):1468-1474.

Donington J, Ferguson M, Mazzone P et al. American College of Chest Physicians and Society of Thoracic Surgeons consensus statement for evaluation and management for high-risk patients with stage I non-small cell lung cancer. Chest. 2012;142(6):1620-1635.

Dupuy DE. Image-guided ablation of lung tumors. 08/30/2016. Up to Date. [UpToDate Web site]. Available at: http://www.uptodate.com/home/index.html [via subscription only]. Accessed January 19, 2018.

Dupuy DE, DiPetrillo T, Gandhi S, et al. Radiofrequency ablation followed by conventional radiotherapy for medically inoperable stage I non-small cell lung cancer. Chest. 2006;129(3):738-745.

Dupuy DE, Zagoria RJ, Akerley W, et al. Percutaneous radiofrequency ablation of malignancies in the lung. AJR Am J Roentgenol. 2000;174(1):57-59.

Ebright MI, Downey RJ, Solomon SB. Radiofrequency ablation for pulmonary metastases: a therapy in evolution. Editorial. J Surg Oncol. 2007;96(5):365-366.

Fernando HC, De Hoyos A, Landreneau RJ, et al. Radiofrequency ablation for the treatment of non-small cell lung cancer in marginal surgical candidates. J Thorac Cardiovasc Surg. 2005;129(3):639-644.

Gage AA, Baust JG. Cryosurgery for tumors. J Am Coll Surg.2007;205(2):342-356.

Gillams AR, Lees WR. Analysis of the factors associated with radiofrequency ablation-induced pneumothorax. Clin Radiology. 2007:62(7):639-644.

Ginsberg MS, Grewal RK, Heelan RT. Lung cancer. Radiol Clin North Am. 2007;46(1):21-43.

Haasbeek CJ, Senan S, Smit EF, et al. Critical review of nonsurgical treatment options for stage I non-small cell lung cancer. Oncologist. 2008;13(3):309-19.

Hess A, Palussičre J, Goyers JF, et al. Pulmonary radiofrequency ablation in patients with a single lung: feasibility, efficacy, and tolerance. Radiology. 2011;258(2):635-642.

Hiraki T, Gobara H, Lishi T, et al. Percutaneous radiofrequency ablation for pulmonary metastases from colorectal cancer: midterm results in 27 patients. J Vasc Interv Radiol. 2007;18(10):1264-1269.

Hiraki T, Gobara H, Mimura H, et al. Percutaneous radiofrequency ablation of clinical stage I non-small cell lung cancer. J Thorac Cardiovasc Surg. 2011;142(1):24-30.

Hiraki T, Sakurai J, Tsuda T, et al. Risk factors for local progression after percutaneous radiofrequency ablation of lung tumors: evaluation based on a preliminary review of 342 tumors. Cancer. 2006;107(12):2873-2880.

Howington JA, Blum MG, Chang AC, et al. Treatment of stage I and II non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest.2013;143(5suppl):e278S-e313S.

Huang L, Han Y, Zhao J, et al. Is radiofrequency thermal ablation a safe and effective procedure in the treatment of pulmonary malignancies? Eur J Cardiothorac Surg. 2011;39(3):348-351.

Jaskolka JD, Kachura JR, Hwang DM, et al. Pathologic assessment of radiofrequency ablation of pulmonary metastases. J Vasc Interv Radiol. 2010;21(11):1689-96.

Kashima M, Yamakado K, Takaki H, et al. Complications after 1000 lung radiofrequency ablation sessions in 420 patients: a single center's experiences. Am J Roentgenol. 2011;197(4):W576-W580.

Kim SR, Han HJ, Park SJ, et al. Comparison between surgery and radiofrequency ablation for stage I non-small cell lung cancer. Eur J Radiol. 2012;81(2):395-9.

Kodama H, Yamakado K, Takaki H, et al. Lung Radiofrequency ablation for the treatment of unresectable recurrent non-small-cell lung cancer after surgical intervention. Cardiovasc Intervent Radiol. 2012;35(3):563-569.

Laganŕ D, Carrafiello G, Mangini M, et al. Radiofrequency ablation of primary and metastatic lung tumors: preliminary experience with a single center device. Surg Endosc.
2006;20(8):1262-1267.

Lanuti M, Sharma A, Digumarthy SR, et al. Radiofrequency ablation for treatment of medically inoperable stage I non-small cell lung cancer. J Thorac Cardiovasc Surg. 2009;137(1):160-166.

Lee H, Jin GY, Han YM, et al. Comparison of Survival Rate in Primary Non-Small-Cell Lung Cancer Among Elderly Patients Treated With Radiofrequency Ablation, Surgery, or Chemotherapy. Cardiovasc Intervent Radiol. 2012;35(2):343-50.

Lee JM, Jin GY, Goldberg SN, et al. Percutaneous radiofrequency ablation for inoperable non-small cell lung cancer and metastases: preliminary report. Radiology. 2004;230(1):125-134.

Lee SH, Choi WJ, Sung SW, et al. Endoscopic cryotherapy of lung and bronchial tumors: a systematic review. Korean J Intern Med. 2011;26(2):137-44.

Lencioni R, Crocetti L, Cioni R, et al. Response to radiofrequency ablation of pulmonary tumours: a prospective, intention-to-treat, multicentre clinical trial (the RAPTURE study). Lancet Oncol. 2008;9(7):621-628.

Liapi E, Geschwind JF. Transcatheter and ablative therapeutic approaches for solid malignancies. J Clin Oncol. 2007;25(8):978-986.

Maiwand MO, Asimakopoulos G. Cryosurgery for lung cancer: clinical results and technical aspects. Technol Cancer Res Treat. 2004;3(2):143-150.

Mathur PN, Wolf KM, Busk MF, et al. Fiberoptic bronchoscopic cryotherapy in the management of tracheobronchial obstruction. Chest. 1996;110(3):718-723.

Moore W, Talati R, Bhattacharji P, et al. Five-year survival after cryoablation of stage I non-small cell lung cancer in medically inoperable patients. J Vasc Interv Radiol. 2015;26(3):312-319.

Nakamura T, Matsumine A, Yamakado K, et al. Lung radiofrequency ablation in patients with pulmonary metastases from musculoskeletal sarcomas [corrected]. Cancer. 2009;115(16):3774-3781.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology™. Non-small cell lung cancer. v.2.2018. [NCCN Web site]. 12/19/2017. Available at: https://www.nccn.org/professionals/physician_gls/default.aspx (via subscription only). Accessed January 19, 2018.

National Institute for Health and Clinical Excellence (NICE). Interventional Procedure Guidance (IPG). IPG 142: Cryosurgery for malignant endobronchial obstruction. [NICE Web site]. 11/01/2005. Available at: http://guidance.nice.org.uk/IPG142. Accessed January 19, 2018.

National Institute for Health and Clinical Excellence (NICE). Interventional Procedure Guidance (IPG). IPG 372: Percutaneous radiofrequency ablation for primary or secondary lung cancers. [NICE Web site]. 12/15/2010 (last update June 2, 2012). Available at: https://www.nice.org.uk/guidance/ipg372/chapter/1-Guidance. Accessed January 19, 2018.

Niu L, Xu K, Mu F. Cryosurgery for lung cancer. J Thorac Dis. 2012;4(4):408-19.
Noppen M, Meysman M, Van Herreweghe R, et al. Bronchoscopic cryotherapy: preliminary experience. Acta Clin Belg. 2001;56(2):73-77.

Okuma T, Matsuoka T, Yamamoto A, et al. Determinants of local progression after computed tomography-guided percutaneous radiofrequency ablation for unresectable lung tumors: 9-year experience in a single institution. Cardiovasc Intervent Radiol. 2010;33(4):787-793.

Onishi H, Shirato H, Nagata Y, et al. Hypofractionated stereotactic radiotherapy (HypoFXSRT) for stage I non-small cell lung cancer: updated results of 257 patients in a Japanese multi-institutional study. J Thorac Oncol. 2007;2(7 Suppl 3):S94-100.

Palussičre J, Italiano A, Descat E, et al. Sarcoma Lung Metastases Treated with Percutaneous Radiofrequency Ablation: Results from 29 Patients. Ann Surg Oncol.
2011;18(13):3771-7.

Pennathur A, Abbas G, Gooding WE, et al. Image-guided radiofrequency ablation of lung neoplasm in 100 consecutive patients by a thoracic surgical service. Ann Thorac Surg. 2009;88(5):1601-1606.

Pennathur A, Abbas G, Qureshi I, et al. Radiofrequency ablation for the treatment of pulmonary metastases. Ann Thorac Surg. 2009;87(4):1030-1036.

Pennathur A, Luketich JD, Abbas G, et al. Radiofrequency ablation for the treatment of stage I non-small cell lung cancer in high-risk patients. J Thorac Cardiovasc Surg. 2007;134(4):857-864.

Pereira PL, Masala S; Cardiovascular and Interventional Radiological Society of Europe (CIRSE). Standards of practice: guidelines for thermal ablation of primary and secondary lung tumors. Cardiovasc Intervent Radiol. 2012;35(2):247-54.

Physician Data Query (PDQ). General Information about Non-Small Cell Lung Cancer (NSCLC) (PDQ®). 12/01/2017. Available at: http://www.cancer.gov/cancertopics/pdq/treatment/non-small-cell-lung/HealthProfessional. Accessed January 19, 2018.

Ratko TA, Vats V, Brock J et al. Local Nonsurgical Therapies for Stage I and Symptomatic Obstructive Non-Small-Cell Lung Cancer . Rockville (MD); Agency for Healthcare Research and Quality, June 2013.

Rose SC, Thistlethwaite PA, Sewell PE, Vance RB. Lung cancer and radiofrequency ablation. J Vasc Interv Radiol. 2006;17(6):927-951.

Rossi S, Dore R, Cascina A, et al. Percutaneous computed tomography-guided radiofrequency thermal ablation of small unresectable lung tumours. Eur Respir J. 2006;27(3):556-563.

Sanderson DR, Neel HB, Fontana RS. Bronchoscopic cryotherapy. Ann Otol Rhinol Laryngol. 1981;90(4 Pt 1):354-358.

Sano Y, Kanazawa S, Gobara H, et al. Feasibility of percutaneous radiofrequency ablation for intrathoracic malignancies: a large single-center experience. Cancer. 2007;109(7):1397-1405.

Schlijper RC, Grutters JP, Houben R, et al. What to choose as radical local treatment for lung metastases from colo-rectal cancer: Surgery or radiofrequency ablation? Cancer Treat Rev. 2014;40(1):60-67.

Scott WJ, Howington J, Feigenberg S, et al.; American College of Chest Physicians. Treatment of non-small cell lung cancer stage I and stage II ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007;132(3 Suppl):234S-242S.

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):e767-74.

Shu Yan Huo A, Lawson Morris D, King J, et al. Use of percutaneous radiofrequency ablation in pulmonary metastases from renal cell carcinoma. Ann Surg Oncol. 2009;16(11):3169-3175.

Simoff MJ. Endobronchial management of advanced lung cancer. Cancer Control. 2001;8(4):337-343.

Simon CJ, Dupuy DE, DiPetrillo TA, et al. Pulmonary radiofrequency ablation: long-term safety and efficacy in 153 patients. Radiology. 2007;243(1):268-335.

Soga N, Yamakado K, Gohara H, et al. Percutaneous radiofrequency ablation for unresectable pulmonary metastases from renal cell carcinoma. BJU Int. 2009;104(6):790-794.

Steinke K, Glenn D, King J, et al. Percutaneous imaging-guided radiofrequency ablation in patients with colorectal pulmonary metastases: 1-year follow-up. Ann Surg Oncol. 2004;11(4):207-212.

Steinke K, Sewell PE, Dupuy D, et al. Pulmonary radiofrequency ablation - an international study survey. Anticancer Res. 2004;24(1):339-343.

Suh R, Reckamp K, Zeidler M, Cameron R. Radiofrequency ablation in lung cancer: promising results in safety and efficacy. Oncology (Williston Park). 2005;19(11Suppl 4):12-21.

Suh RD, Wallace AB, Sheehan RE, et al. Unresectable pulmonary malignancies: CT-guided percutaneous radiofrequency ablation--preliminary results. Radiology. 2003;229(3):821-829.

Tanoue LT, Gettinger S. Treatment of lung cancer in older patients. Clin Chest Med. 2007;28(4):735-749.

Thanos L, Mylona S, Pomoni M, et al. Percutaneous radiofrequency thermal ablation of primary and metastatic lung tumors. Eur J Cardiothorac Surg. 2006;30(5):797-800.

Thanos L, Mylona S, Ptohis N, et al. Percutaneous radiofrequency thermal ablation in the management of lung tumors: presentation of clinical experience on a series of 35 patients. Diagn Interv Radiol. 2009;15(4):290-296.

Thomas CF, Jett JR, Strosberg, JR. Lung neuroendocrine (carcinoid) tumors: Treatment and prognosis. 12/05/2017. Up to Date. [UpToDate Web site]. Available at: http://www.uptodate.com/home/index.html [via subscription only]. Accessed January 19, 2018.

Thurer RJ. Cryotherapy in early lung cancer. Chest. 2001;120(1):3-5.

vanSonnenberg E, Shankar S, Morrison PR, et al. Radiofrequency ablation of thoracic lesions: part 2, initial clinical experience – technical and multidisciplinary considerations in 30 patients. AJR Am J Roentgenol. 2005;184(2):381-390.

Wood DE. Management of malignant tracheobronchial obstruction. Surg Clin North Am. 2002;82(3):621-642.

Yamagami T, Kato T, Hirota T, et al. Risk factors for occurrence of local tumor progression after percutaneous radiofrequency ablation for lung neoplasms. Diagn Interv Radiol. 2007;13(4):199-203.

Yamakado K, Hase S, Matsuoka T, et al. Radiofrequency ablation for the treatment of unresectable lung metastases in patients with colorectal cancer: a multicenter study in Japan. J Vasc Interv Radiol. 2007;18(3):393-398.

Yamakado K, Inoue Y, Takao M, et al. Long-term results of radiofrequency ablation in colorectal lung metastases: single center experience. Oncol Rep. 2009;22(4):885-891.

Yan TD, King J, Ebrahimi A, et al. Hepatectomy and lung radiofrequency ablation for hepatic and subsequent pulmonary metastases from colorectal carcinoma. J Surg Oncol. 2007;96(5):367-373.

Zemlyak A, Moore WH, Bilfinger TV. Comparison of survival after sublobar resections and ablative therapies for stage I non-small cell lung cancer. J Am Coll Surg. 2010;211(1):68-72.

Zhu JC, Yan TD, Glenn D, et al. Radiofrequency ablation of lung tumors: feasibility and safety. Ann Thorac Surg. 2009;87(4):1023-1028.

Zhu JC, Yan TD, Morris DL. A systematic review of radiofrequency ablation for lung tumors. Ann Surg Oncol. 2008; 15(6):1765-1774.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

31641, 32994, 32998


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

C34.00 Malignant neoplasm of unspecified main bronchus

C34.01 Malignant neoplasm of right main bronchus

C34.02 Malignant neoplasm of left main bronchus

C34.10 Malignant neoplasm of upper lobe, unspecified bronchus or lung

C34.11 Malignant neoplasm of upper lobe, right bronchus or lung

C34.12 Malignant neoplasm of upper lobe, left bronchus or lung

C34.2 Malignant neoplasm of middle lobe, bronchus or lung

C34.30 Malignant neoplasm of lower lobe, unspecified bronchus or lung

C34.31 Malignant neoplasm of lower lobe, right bronchus or lung

C34.32 Malignant neoplasm of lower lobe, left bronchus or lung

C34.80 Malignant neoplasm of overlapping sites of unspecified bronchus and lung

C34.81 Malignant neoplasm of overlapping sites of right bronchus and lung

C34.82 Malignant neoplasm of overlapping sites of left bronchus and lung

C34.90 Malignant neoplasm of unspecified part of unspecified bronchus or lung

C34.91 Malignant neoplasm of unspecified part of right bronchus or lung

C34.92 Malignant neoplasm of unspecified part of left bronchus or lung

C7A.090 Malignant carcinoid tumor of the bronchus and lung

C78.00 Secondary malignant neoplasm of unspecified lung

C78.01 Secondary malignant neoplasm of right lung

C78.02 Secondary malignant neoplasm of left lung



HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

11.00.16g
04/09/2018This policy has undergone a routine review, and the coverage position for cryosurgical ablation for lung cancer has been revised from experimental/investigational to medically necessary with the following associated criteria:
  • The individual has early-stage non-small cell lung cancer and is a poor surgical candidate

11.00.16f
01/01/2018This policy has been identified for the CPT code update, effective 01/01/2018.

The following CPT code has been termed from this policy: 0340T
The following CPT has been added to this policy: (experimental/investigational) 32994
The following CPT code narrative has been revised in this policy: 32998


Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date: 04/09/2018
Version Issued Date: 04/09/2018
Version Reissued Date: N/A

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