Ablative Therapy (L30312)

Contractor Information

Contractor Name
Wisconsin Physicians Service Insurance Corporation		 Contractor Number
00951, 00952, 00953, 00954, 52280, 05101, 05201, 05301, 05401, 05102, 05202, 05302, 05402		 Contractor Type
Carrier - FI - MAC

LCD Information

Document Information
LCD ID Number
L30312

LCD Title
Ablative Therapy

Contractor's Determination Number
GSURG-033

AMA CPT/ADA CDT Copyright Statement
CPT codes, descriptions and other data only are copyright 2010 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Primary Geographic Jurisdiction


Oversight Region

Original Determination Effective Date
For services performed on or after 09/15/2009

Original Determination Ending Date


Revision Effective Date
For services performed on or after 04/25/2011

Revision Ending Date


CMS National Coverage Policy
Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary.

Title XVIII of the Social Security Act, Section 1833(e). This section prohibits Medicare payment for any claim, which lacks the necessary information to process the claim.

Title XVIII of the Social Security Act section 1862 (a)(7). This section excludes routine physical examinations and services
Indications and Limitations of Coverage and/or Medical Necessity
Ablative procedures have been in the armamentarium of tumor therapy for many years. Recent technological advances have allowed the use of ablative procedures in virtually any organ system.

Radiofrequency ablation (RFA), which can be performed laparoscopically or percutaneously, involves the passage of high-frequency electrical current into the tumor mass. Guided by images from intraoperative computed tomography (CT) or ultrasound (US), the surgeon inserts a small electrode into the tumor. Applying a high-frequency electrical current generates heat within the renal mass and ablates tissue around the electrode. Although heat is generated in the tissue around the electrode, rather than in the electrode itself, some RFA systems circulate chilled water or saline through the electrode during thermoablation to minimize charring of renal tissue and increase the heat-generating capacity of the targeted tissue.

Cryotherapy, also called cryosurgery, cryoablation or targeted cryoablation therapy, is a minimally invasive treatment that uses extreme cold to freeze and destroy diseased tissue, including cancer cells. Although cryotherapy and cryoablation can be used interchangeably, the term "cryosurgery" is reserved best for cryotherapy performed using an open, surgical approach. In cryotherapy, liquid nitrogen or argon gas is applied to diseased cells located outside or inside the body. Physicians use image-guidance techniques such as ultrasound, computed tomography (CT) or magnetic resonance (MR) to help guide these freezing substances to treatment sites located inside the body.
Tumor ablation destroys the tumor without surgically removing it by placing ablation probes at precise locations. Therefore, it should be performed in conjunction with computed tomography scan, ultrasound or magnetic resonance guidance to ensure proper placement.

This LCD does not address cardiac ablative procedures or endometrial ablative procedures. For all indications the cryosurgical, radiofrequency ablation (RFA), or any other ablative device used must be FDA-approved for the indications used.

A. Liver Tumors
Cryosurgery (Cryoablation) and Radiofrequency Ablation for Treatment of Liver Tumors
Cryosurgery is a means for surgical destruction of diseased tissue utilizing sub-zero temperatures. It has been used for years in many medical fields including dermatology, neurosurgery, proctology, gynecology, and otolaryngology. In the past two decades, much work has been done in applying this modality to the treatment of liver tumors, both primary and metastatic. The biggest breakthrough in the field of cryosurgery for liver tumors has been the application of intraoperative ultrasound both to detect small lesions and to monitor the cryosurgical destruction process in order to assure complete ablation of the desired lesion with a margin of normal tissue. In the treatment of liver tumors, cryosurgical destruction is often used in addition to surgical resection.

In 2000, the FDA approved the use of radiofrequency induced tumor ablation (RFA) for hepatic tumors. WPS believes the indications for RFA are the same as for cryosurgery.

1. Cryosurgery and RFA in the treatment of certain selected primary and secondary liver tumors are considered safe and effective in the following clinical scenarios:
a. Primary hepatocellular carcinoma when conventional surgical resection is felt to be contraindicated or when ablation is used as an adjunct to surgical resection; and
b. Primary carcinoma of the colon, small intestine, gall bladder, ovary, and neuroendocrine system, or other sites metastasized to the liver.
c. Metastatic tumors with the following qualifying conditions:
- The primary cancer site must be effectively controlled.
- The metastatic lesions must be limited to the liver and not present in other organs.
d. The cryosurgical device and RFA device used must be FDA approved for the
indications used.

2. In the case of carcinomas metastatic to the liver, the following qualifying conditions for coverage must be met:
a. The primary cancer site must be effectively controlled;
b. The metastatic lesions must be liver-dominant in terms of symptoms and clinical concern; any extrahepatic disease should be minimal and well-controlled.
c. The open laparotomy approach or percutaneous approach may be used.
d. The patient must have no more than 3 liver metastases, except in rare instances (such as multiple neuroendocrine liver metastases).
e. No lesion should be larger than 7 cm. in size.

Note:
- Primary carcinomas of the breast, lung, stomach, pancreas, adenocarcinoma of unknown origin and other primary cancers which are widely disseminated at the same time liver metastases are present are not appropriate for cryosurgical ablation.

B. Bone Tumors:
Percutaneous RFA of osteoid osteomas has become the preferred method of therapy for these benign lesions. RFA and cryotherapy have both been shown to be safe and effective in the palliation of metastatic bone tumors.

C. Renal Tumors:
Although open partial nephrectomy has been the gold standard for excision of renal tumors, minimally invasive approaches offer excellent results with lower morbidity and sparing renal function. The ablative techniques, cryoablation and radiofrequency ablation, have been relatively safe. At present, RF ablation is probably better suited for peripheral, exophytic masses in which higher blood flow and the collecting system are not problems.

Indications:
1. Solid renal masses less than or equal to 3 cm. Larger masses would be appropriate in conjunction with vascular or chemical ablation. The larger masses can be devascularized shrinking them to an effective size for treatment. The scanned mass could still be larger than 3cm - (RFA of a renal mass may require multiple cycles of current application with the electrode placed at different sites within the mass. For renal tumors larger than 3 centimeters (cm), re-treatment may be required on a subsequent day with multiple cycles of renal tissue ablation on each day of treatment. In the months following RFA, patients undergo periodic evaluations by CT or magnetic resonance imaging (MRI) to monitor for regrowth of the ablated mass); and;

2. Lesions in solitary kidney or patients with increased surgical risk/renal insufficiency; and

Examples:
a. selected patients with small and incidentally detected renal cortical lesions
b. in patients with a genetic predisposition to multiple tumors, or
c. in patients with a solitary kidney, or
d. when bilateral tumour growth is present.
e. are poor surgical candidates due to poor renal function (e.g., RCC detected in an anatomical or functional solitary kidney when resection would result in the need for dialysis) and/or
f. comorbid disease, and
g. patients at high risk for the development of additional RCC in the future in whom the least invasive nephron-sparing approach is desirable (e.g., patients with hereditary diseases; patients with synchronous RCC).

3. A limit of 3 or less lesions; and

4. Biopsy proven or image documentation consistent with renal cell cancer, i.e. characteristics that are suspicious for malignancy.
A substantial percentage of patients referred for percutaneous ablation of renal tumors had benign masses. If CT or MRI alone cannot be used to diagnose a benign entity, patients may need to undergo a biopsy before the treatment session. Better techniques for subtyping renal tumors (eg serologic, genetic and/or radiographic) are required to aid in selecting patients who need treatment and determining which of those may be most suitable for ablative therapy.

Limitations:
1. Small centrally located lesions or lesions adjacent to the renal hilum should not be considered.
2. Due to risk of tumor spillage from cyst contents with puncture from a cryoprobe, not indicated for primarily cystic lesions.

D. Breast Tumors:
There is ongoing research into the use of ablation in both benign and malignant breast tumors. At present the research is too preliminary to determine the role of ablation in breast treatment. Ablation of breast lesions is not yet proven effective and therefore is not covered by WPS Medicare.

E. Lung Tumors:

Radio frequency Ablation
The literature for pulmonary nodule ablation consists of several small studies of heterogeneous patients with short-term follow-up. All studies commented on a promising technology with further studies needing to be performed. There is no breakdown as to indications or durability of treatment for primary, metastatic, or multiple lesions treated percutaneously. Per the FDA, lack of safety and efficacy data precludes specific approval of ablation devices in lung cancer. Therefore, percutaneous ablation of pulmonary lesions remains an investigational modality. At this time this procedure will not be covered outside of a Medicare-approved clinical trial.

Cryotherapy
Endobronchial cryosurgery is a palliative technique, with the aim of alleviating symptoms and improving the patient's performance status. Patients with lung cancers can develop endobronchial lesions that obstruct the major airways, causing symptoms such as dyspnea, cough, hemoptysis and postobstructive pneumonia. Future randomized trials, comparing the results of endobronchial cryosurgery with other forms of palliative treatment for lung cancer are needed. At this time this procedure will not be covered outside of a Medicare- approved clinical trial.

F. Uterine leiomyoma, Percutaneous:
The use of RFA in symptomatic uterine leiomyomata is being studied in several centers. The issue of durability of the therapy, repeat procedures, and efficacy superior to other acceptable methods of therapy has not been determined. We have determined that RFA of uterine leiomyomata is not proven effective and thus not covered by Medicare.

This contractor will consider the ablation by any method of tumors not specifically mentioned above to be investigational and not covered by Medicare.


Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
083x Ambulatory Surgery Center
085x Critical Access Hospital

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

Note: Providers are reminded that not all the CPT/HCPCS codes listed can be billed with all TOB and RC codes listed. CPT/HCPCS codes are required to be billed with specific TOB and RC codes.
Providers are encouraged to refer to the CMS Internet Only Manual (IOM) Pub. 100.4, Claims Processing Manual, for further guidance.
360X Operating Room Services - General Classification
0710 Recovery Room - General Classification

CPT/HCPCS Codes

Group 1
The following codes, when used as described below, are considered not proven effective and will be denied as such:

19105ABLATION, CRYOSURGICAL, OF FIBROADENOMA, INCLUDING ULTRASOUND GUIDANCE, EACH FIBROADENOMA
19499UNLISTED PROCEDURE, BREAST
32999UNLISTED PROCEDURE, LUNGS AND PLEURA
0071TFOCUSED ULTRASOUND ABLATION OF UTERINE LEIOMYOMATA, INCLUDING MR GUIDANCE; TOTAL LEIOMYOMATA VOLUME LESS THAN 200 CC OF TISSUE
0072TFOCUSED ULTRASOUND ABLATION OF UTERINE LEIOMYOMATA, INCLUDING MR GUIDANCE; TOTAL LEIOMYOMATA VOLUME GREATER OR EQUAL TO 200 CC OF TISSUE

Group II
The following codes, when used as described below, are covered services.

20982ABLATION, BONE TUMOR(S) (EG, OSTEOID OSTEOMA, METASTASIS) RADIOFREQUENCY, PERCUTANEOUS, INCLUDING COMPUTED TOMOGRAPHIC GUIDANCE
20999UNLISTED PROCEDURE, MUSCULOSKELETAL SYSTEM, GENERAL
47370LAPAROSCOPY, SURGICAL, ABLATION OF 1 OR MORE LIVER TUMOR(S); RADIOFREQUENCY
47371LAPAROSCOPY, SURGICAL, ABLATION OF 1 OR MORE LIVER TUMOR(S); CRYOSURGICAL
47380ABLATION, OPEN, OF 1 OR MORE LIVER TUMOR(S); RADIOFREQUENCY
47381ABLATION, OPEN, OF 1 OR MORE LIVER TUMOR(S); CRYOSURGICAL
47382ABLATION, 1 OR MORE LIVER TUMOR(S), PERCUTANEOUS, RADIOFREQUENCY
50250ABLATION, OPEN, 1 OR MORE RENAL MASS LESION(S), CRYOSURGICAL, INCLUDING INTRAOPERATIVE ULTRASOUND GUIDANCE AND MONITORING, IF PERFORMED
50542LAPAROSCOPY, SURGICAL; ABLATION OF RENAL MASS LESION(S), INCLUDING INTRAOPERATIVE ULTRASOUND GUIDANCE AND MONITORING, WHEN PERFORMED
50592ABLATION, 1 OR MORE RENAL TUMOR(S), PERCUTANEOUS, UNILATERAL, RADIOFREQUENCY
50593ABLATION, RENAL TUMOR(S), UNILATERAL, PERCUTANEOUS, CRYOTHERAPY
76940ULTRASOUND GUIDANCE FOR, AND MONITORING OF, PARENCHYMAL TISSUE ABLATION
77013COMPUTED TOMOGRAPHY GUIDANCE FOR, AND MONITORING OF, PARENCHYMAL TISSUE ABLATION
77022MAGNETIC RESONANCE GUIDANCE FOR, AND MONITORING OF, PARENCHYMAL TISSUE ABLATION

ICD-9 Codes that Support Medical Necessity

ICD-9 Codes that Support Medical Necessity
Note: ICD-9 codes must be coded to the highest level of specificity.
For use with Group II CPT Codes above

CPT codes: 47370, 47371, 47380, 47381, 47382

152.2 - 152.9MALIGNANT NEOPLASM OF ILEUM - MALIGNANT NEOPLASM OF SMALL INTESTINE UNSPECIFIED SITE
153.0 - 153.9MALIGNANT NEOPLASM OF HEPATIC FLEXURE - MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE
154.0 - 154.8MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION - MALIGNANT NEOPLASM OF OTHER SITES OF RECTUM RECTOSIGMOID JUNCTION AND ANUS
155.0MALIGNANT NEOPLASM OF LIVER PRIMARY
156.0MALIGNANT NEOPLASM OF GALLBLADDER
156.1MALIGNANT NEOPLASM OF EXTRAHEPATIC BILE DUCTS
197.7MALIGNANT NEOPLASM OF LIVER SECONDARY
235.3NEOPLASM OF UNCERTAIN BEHAVIOR OF LIVER AND BILIARY PASSAGES
239.0NEOPLASM OF UNSPECIFIED NATURE OF DIGESTIVE SYSTEM
259.2CARCINOID SYNDROME
CPT codes: 50250, 50542, 50592, 50593
189.0MALIGNANT NEOPLASM OF KIDNEY EXCEPT PELVIS
198.0SECONDARY MALIGNANT NEOPLASM OF KIDNEY
233.9CARCINOMA IN SITU OF OTHER AND UNSPECIFIED URINARY ORGANS
CPT code: 20982
198.5SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW
213.0 - 213.9BENIGN NEOPLASM OF BONES OF SKULL AND FACE - BENIGN NEOPLASM OF BONE AND ARTICULAR CARTILAGE SITE UNSPECIFIED

Diagnoses that Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity

General Information

Documentations Requirements
Documentation Requirements
1. Criteria listed in "Indications and Limitations of Coverage" must be met for Medicare reimbursement.

2. If cryosurgery or RFA is performed in addition to surgical resection, specific CPT codes must be submitted to reflect this along with the pertinent modifiers. The operative report must specify both surgical resection and cryosurgery or RITA ablation were performed.

3. There must be a written report of the procedure performed in the patient's medical records and copies of the medical records must be made available upon Medicare request. When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act. When requesting a written redetermination (formerly appeal), providers must include all relevant documentation with the request.

4. For liver procedures: In rare instances (such as multiple neuroendocrine liver metastases) more than 3 liver metastases might be appropriately treated with ablation or a combination of ablation and surgical excision. In such cases, the claim should be re-submitted for review with a detailed letter of explanation of the clinical situation necessitating treatment of more than 3 metastases. In addition, a detailed operation note should be submitted with the claim in this situation.

5. The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.

Appendices
Utilization Guidelines
Reasons for Denial
1. All other indications not listed in the "Indications and Limitations of Coverage" section of this policy;
2. The service is not medically necessary;
3. The medical record does not verify that the service described by the HCPCS code was provided;
4. The service does not follow the guidelines of this policy.
5. Services performed using other than FDA-approved equipment will be denied as non-covered.
6. CPT codes should only be billed once per day. Additional billing of these services on the same date of service will deny as not medically necessary.
Sources of Information and Basis for Decision
Liver
Cryosurgery:
Kane, R.A. Ultrasound-Guided Hepatic Cryosurgery for Tumor Ablation. Seminars in Interventional Radiology; 1993, Vol. 10, No 2:132-142.
New Technology - Surgery Issues Carrier Medical Directors Clinical Work Group.
Onik, G.M. et al Cryosurgery of Liver Cancer. Seminars in Surgical Oncology; 1993, Vol. 9:309-317.
Ravikumar, T.S. et al. A 5-Year Study of Cryosurgery in the Treatment of Liver Tumors. Archives of Surgery ; 1991, Vol. 126:1520-1524.
Steele, Glenn, Jr. Cryoablation in Hepatic Surgery. Seminars in Liver Disease: May 1994 Vol. 14, No 2; 120-125.
Stone, Michael D. et al. 1990. Surgical Therapy for Recurrent Liver Metastases from Colorectal Cancer. Archives of Surgery Vol. 125:718-722.
Zhou, X.,Tang, Z. et al. 1993. The Role of Cryosurgery in the Treatment of Hepatic Cancer Cancer Research Clinical Oncology 120:100-102.

Radiofrequency Ablation (RFA):
Berber, Eren, Pelley, Robert, et al. Predictors of Survival After Radiofrequency Thermal Ablation of Colorectal Cancer Metastases to the Liver: A Prospective Study. Journal of Clinical Oncology, March 2005, Vol. 23, No 7, 1358-1364
Bleicher RJ., Allegra DP., Nora, DT., Wood, TF., Foshag, L.J., Bilchik,AJ., Radiofrequency ablation in 447 complex unresectable liver tumors: Lessons learned. Annals of Surgery Oncology 2003: 10:52-58.
Cabassa et. Al., "Radiofrequency ablation of hepatocellular carcinoma: Long-term experience with expandable needle electrodes", American Journal of Radiology, Vol 186, may 2006, pp 316-321
Curley, S.A., Izzo, F., et al. Radiofrequency ablation of hepatocellular cancer in 110 patients with cirrhosis, Annals of Surgery, September 2000, Vol. 232, No. 3: 381-391
Curley, S.A., Marra, Paola, et al. Early and Late Complications After Radiofrequency Ablation of Malignant Liver Tumors in 608 Patients. Annals of Surgery 2004, Vol. 239, No 4; 450-458
Goldberg, S.N., Gazelle G.S., et al. Treatment of intrahepatic malignancy with radiofrequency ablation: radiologic-pathologic correlation, Cancer, June 1, 2000, Vol. 88, No. 11: 2452-2463
Iannitti, David, et al; Radiofrequency Ablation. Arch Surg. 2002: 137; 422-427
Radio Therapeutics Website
RITA Medical Systems Website
Siperstein, A., Garland, A., et al. Laparoscopic radiofrequency ablation of primary and metastic liver tumors: Technical considerations. Surgical Endoscopy, April 2000, Vol. 14, No.4: 400-405
Solbiati et. Al., "percutaneous radiofrequency ablation of hepatic metastases from colorectal cancer: Long-term results in 117 patients", Radiology, Vol 221, No 1, October 2001, pp 159-166

Kidney
Trabulsi et. Al., "New approaches to the minimally invasive treatment of kidney tumors", The Cancer Journal, Vol 11 no 1, Jan/Feb 2005, pp 57-63
Deane and Clayman, "Review of minimally invasive renal therapies: Needle-based and extracorporeal", Urology, Vol 68, July 2006, pp 26-37

Radiofrequency Ablation
*Kemal Tuncali et. Al, Evaluation of Patients Referred for Percutaneous Ablation of Renal Tumors: Importance of a Preprocedural Diagnosis; Am J Roentgenol 183(3):575-582, 2004. © 2004 American Roentgen Ray Society
*Levinson, Adam W. et. Al, Long-Term Oncological and Overall Outcomes of Percutaneous Radio Frequency Ablation in High Risk Surgical Patients With a Solitary Small Renal Mass; The Journal of Urology, Vol. 180, 499-504, August 2008
*Gervais DA, McGovern FJ, Arellano RS, McDougal, WS, Mueller, PRo Renal cell carcinoma: clinical experience and technical success with radio-frequency ablation of 42 tumors. Radiology 2003 Feb; 226(2):417-24.
*Gervais, DA, McGovern, FJ, Arellano, RS, et al. Radiofrequency ablation of renal cell carcinoma: part I, indications, results, and role in patient management over a 6-year period and ablation of 100 tumors. AJR 2005; 185:64-71.
*Gervais, DA, McGovern, FJ, Arellano, RS, et al.; Radiofrequency Ablation of Renal Cell Carcinoma: Part 2, Lessons Learned with Ablation of 100 Tumors; AJR: 185, July 2005
*Mayo-Smith WW, et. al ; Imaging-guided percutaneous radiofrequency ablation of solid renal masses: techniques and outcomes of 38 treatment sessions in 32 consecutive patients. AJR Am J Roentgenol 2003; June 180(6):15038.
*Schultze, D, Morris, CS, Shave, AD, et. al. Radiofrequency Ablation of Renal Transitional Cell Carcinoma with Protective Cold Saline Infusion. J Vasc Interv Radiol 2003; 14:489492
*Zagoria RJ. Percutaneous image-guided radiofrequency ablation of renal malignancies. Radiol Clin North Am. 2003; Sep 41(5):1067-75.
*Zagoria R.J., Hawkins A.D., Clark P.E., et. al.Percutaneous CT-Guided Radiofrequency
Ablation of Renal Neoplasms: Factors Influencing Success. AJR Am J Roentgenol 2004; July
183(1):201-7.

Cryotherapy
*Littrup Peter J.; CT-guided Percutaneous Cryotherapy of Renal Masses; J Vasc Interv Radiol 2007; 18:383 392
Gill et. Al., "Renal Cryoablation: Outcome at 3 years" The Journal of Urology, Vol 173, 1903- 1907, June 2005
Weld and Landman, "Comparison of Cryoablation, radiofrequency ablation and high-risk focused ultrasound for treating small renal tumors", British Journal of Urology, Vol. 96, pp 1224-1229, 2005
Davol, Fulmer, and Rukstalis, "Long-term results of Cryoablation for renal cancer and complex renal masses", Urology, Vol 68, July 2006, pp 2-6
Schwartz et. Al., "Cryoablation of small peripheral renal masses: A retrospective analysis", Urology, Vol. 68, July 2006, pp 14-18
Hegarty et. Al., "Probe-ablative nephron-sparing surgery: Cryoablation versus radiofrequency ablation", Urology, Vol 68, July 2006, pp 7-13
Lawatsch et. Al., "Intermediate results of laparoscopic cryoablation in 59 patients at the Medical College of Wisconsin", The Journal of Urology, Vol 175, April 2006, pp 1225-1229
*Silverman SG, et. Al; Renal tumors: MR imaging-guided percutaneous cryotherapy- initial experience in 23 patients. Radiology 236: 716-724, 2005.
*George Asimakopoulos, Julia Beeson, Joanna Evans and M. Omar Maiwand; Cryosurgery for Malignant Endobronchial Tumors; Chest 2005; 127; 2007-2014


Lung
Akeboshi et. Al., "Percutaneous radiofrequency ablation of lung neoplasms: initial therapeutic response", Journal of Vascular Interventional Radiology, Vol 15, No 5 May 2004, pp 463-470
Yasui et. al., "Thoracic tumors treated with CT-guided radiofrequency Ablation: initial experience", Radiology, Vol 231, No 3, June 2004, pp 850-857
Gadaleta et. Al., "Radiofrequency thermal ablation of 69 Lung neoplasms", Journal of Chemotherapy, Vol. 16 Supplement n. 5, 2004, pp 86-89
de Baere et. Al., "Midterm local efficacy and survival after radiofrequency ablation of lung tumors with minimum follow-up of 1 year", Radiology, Vol 240, No 2, August 2006, pp 587-596
*Simon, Caroline J, et al; Pulmonary Radiofrequency Ablation: Long-term Safety and Efficacy in 153 Patients; Radiology: Volume 243: Number 1 April 2007
*Timmerman, Robert D., et al; Local Surgical, Ablative, and Radiation Treatment of Metastases
CANCER J CLIN 2009; 59:145-170
*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 Oncology. 2008; 9:621-628.
*FDA Public Health Notification: Radiofrequency Ablation of Lung Tumors - Clarification of Regulatory Status; Issued: September 24, 2008

Bone
Callstrom et. Al., "Image-guided ablation of painful metastatic bone tumors: A new and effective approach to a difficult problem", Skeletal Radiology, Vol 35, 2006, pp 1-15
Goetz et. Al., "Percutaneous image-guided radiofrequency ablation of painful metastases involving bone: A multicenter study", Journal of Clinical Oncology, Vol 22, No 2, January 15, 2004, pp 300-306
Rosenthal et. Al., "Osteoid osteoma: Percutaneous treatment with radiofrequency energy", Radiology, Vol. 229, No 1, October 2003, pp 171-175

Breast
American Cancer Society (ACS). Breast cancer. Sep 11, 2007. Available at URL address: http://documents.cancer.org/acs/groups/cid/documents/webcontent/003090-pdf.pdf
American College of Radiology Imaging Network (ACRIN). Breast disease site committee
research strategy.
American Society of Breast Surgeons. Management of fibroadenomas of the breast. Dec 8, 2005.
American Society of Breast Surgeons. Position statement on ablative and percutaneous treatment of breast cancer. Apr 24, 2002.
Angiodynamics Incorporated. RITA® Model 1500X RF. 2007. Available at URL address: http://www.angiodynamics.com/products/rita-model-1500
Bland KL, Gass J, Klimberg VS. Radiofrequency, cryoablation, and other modalities for breast
cancer ablation. Surg Clin North Am. 2007 Apr;87(2):539-50.
Brown DB. Concepts, considerations, and concerns on the cutting edge of radiofrequency ablation. J Vasc Interv Radiol. 2005 May;16(5):597-613.
Burak WE Jr, Agnese DM, Povoski SP, Yanssens TL, Bloom KJ, Wakely PE, Spigos DG. Radiofrequency ablation of invasive breast carcinoma followed by delayed surgical excision. Cancer. 2003 Oct 1;98(7):1369-76.
Earashi M, Noguchi M, Motoyoshi A, Fujii H. Radiofrequency ablation therapy for small breast cancer followed by immediate surgical resection or delayed mammotome excision. Breast Cancer. 2007;14(1):39-47.
ESMO Guidelines Working Group, Pestalozzi B. Primary breast cancer: ESMO clinical recommendations for diagnosis, treatment and follow-up. Ann Oncol. 2007 Apr;18 Suppl 2:ii5-8.
Fornage BD, Sneige N, Ross MI, Mirza AN, Kuerer HM, Edeiken BS, Ames FC, Newman LA, Babiera GV, Singletary SE. Small (< or = 2-cm) breast cancer treated with US-guided radiofrequency ablation: feasibility study. Radiology. 2004 Apr;231(1):215-24. Epub 2004 Feb

Other
*Damian E. Dupuy, MD, and S. Nahum Goldberg, MD, Image-guided Radiofrequency Tumor Ablation: Challenges and Opportunities Part II; J Vasc Interv Radiol 2001; 12:1135 1148
Medical consultants
Other Medicare contractor policies
Advisory Committee Meeting Notes
Meeting Date:
Wisconsin: 01/16/2009
Illinois: 01/28/2009
Michigan: 01/07/2009
Minnesota: 01/22/2009
J-5 MAC (IA,KS,MO, NE) 02/12/2009

Start Date of Comment Period
02/12/2009
End Date of Comment Period
03/29/2009
Start Date of Notice Period
03/01/2010
Revision History Number
X
Revision History Explanation
03/01/2010, Added CPT code 47382 to the list of covered codes. It was inadvertently omitted from the original document

7/24/2009 Revisions to Draft LCD and removal of Coding And Billing Article completely. Released to Final.

06/29/09 Removed contractor 05392 as it is combining with WMO as one contractor number effective 8/1/09 bw


11/15/2009 - The description for CPT/HCPCS code 47370 was changed in group 2
11/15/2009 - The description for CPT/HCPCS code 47371 was changed in group 2
11/15/2009 - The description for CPT/HCPCS code 47380 was changed in group 2
11/15/2009 - The description for CPT/HCPCS code 47381 was changed in group 2
03/01/2010, Added CPT code 47382 to the list of covered codes. It was inadvertently omitted from the original document; 09/15/2009


04/19/2010 In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of American Somoa, California, Guam, Hawaii, Nevada and Northern Mariana Islands were removed from this LCD because claims processing for those states are transitioning from FI Contractor Wisconsin Physician Services (WPS - 52280) to MAC Part A Contractor  Palmetto.

8/1/2010 - The description for Bill Type Code 12 was changed
8/1/2010 - The description for Bill Type Code 13 was changed
8/1/2010 - The description for Bill Type Code 83 was changed
8/1/2010 - The description for Bill Type Code 85 was changed

8/1/2010 - The description for Revenue code 0360 was changed
8/1/2010 - The description for Revenue code 0361 was changed
8/1/2010 - The description for Revenue code 0362 was changed
8/1/2010 - The description for Revenue code 0367 was changed
8/1/2010 - The description for Revenue code 0369 was changed
8/1/2010 - The description for Revenue code 0710 was changed

8/1/2010 - Revenue code 0719 was deleted

10/18/2010 - In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Colorado, New Mexico, Oklahoma and Texas were removed from this LCD because claims processing for those states are transitioning from FI Wisconsin Physicians Service (52280) to MAC Part A Trailblazer (04901).

11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:
19105 descriptor was changed in Group 1
20982 descriptor was changed in Group 2
50250 descriptor was changed in Group 2
50542 descriptor was changed in Group 2
76940 descriptor was changed in Group 2

02/21/2011 In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania were removed from this LCD because claims processing for these states are transitioning from FI Wisconsin Physician Service (WPS 52280) to MAC Part A contractor Highmark (12901).

04/25/2011 Annual review
Reason for Change
Last Reviewed On Date
04/25/2011
Related Documents
This LCD has no Related Documents.

LCD Attachments
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Page Last Updated: Thursday, 15-Dec-2011 12:20:27 CST