Cryosurgery
Cryosurgery is a technique that utilizes freezing of the cells to treat primary or secondary hepatic tumors. It is indicated for patients whose disease may be deemed unresectable by location or number of tumors, who have comorbid disease that makes them poor surgical candidates, or who refuse hepatic resection.
Cryosurgery involves operative placement of a cryoprobe into the center of a tumor. When the center of the tumor is located, liquid nitrogen or argon gas is pumped into the probe. The tumor freezes from the center and expands outward. To guide the cryoprobe and to monitor the freezing of cells, the physician uses ultrasound. The freezing process is continued until the tumor is frozen to one centimeter beyond the confines of the tumor.
Radiofrequency Ablation
Radiofrequency Ablation (RFA) utilizes heat derived from radiofrequency energy to destroy liver tumors. RFA may be performed via open surgical, laparoscopic or percutaneous approaches.
Open Surgical
Following anesthesia and standard surgical preparation, an abdominal incision is made to directly visualize the liver. Ultrasound is performed to assess blood flow and localize each tumor to be treated. The radiofrequency needle electrode is then introduced into and around the lesion(s), and radiofrequency energy is delivered to ensure adequate tumor necrosis and tumor-free margins. Following successful ablation, the abdominal cavity is irrigated and hemostasis is confirmed. The incision is closed and dressed.
Following anesthesia and standard surgical preparation, an abdominal incision is made to directly visualize the liver. Ultrasound is performed to assess blood flow and localize each tumor to be treated. The radiofrequency needle electrode is then introduced into and around the lesion(s), and radiofrequency energy is delivered to ensure adequate tumor necrosis and tumor-free margins. Following successful ablation, the abdominal cavity is irrigated and hemostasis is confirmed. The incision is closed and dressed.
Laparoscopic
Following anesthesia and standard surgical preparation, an abdominal incision is made and a trocar is placed. The laparoscope is introduced so that the abdominal cavity can be directly visualized. A second incision is made and another trocar is placed laterally to the first incision and trocar. The laparoscopic ultrasound is then performed to visualize the liver and lesion(s) to be treated. The radiofrequency needle electrode is then introduced into and around the lesion(s) and radiofrequency energy delivered to ensure adequate tumor necrosis and tumor-free margins. Following successful ablation, the abdominal cavity is irrigated and hemostasis is confirmed. The trocars are removed and incisions closed and dressed.
Following anesthesia and standard surgical preparation, an abdominal incision is made and a trocar is placed. The laparoscope is introduced so that the abdominal cavity can be directly visualized. A second incision is made and another trocar is placed laterally to the first incision and trocar. The laparoscopic ultrasound is then performed to visualize the liver and lesion(s) to be treated. The radiofrequency needle electrode is then introduced into and around the lesion(s) and radiofrequency energy delivered to ensure adequate tumor necrosis and tumor-free margins. Following successful ablation, the abdominal cavity is irrigated and hemostasis is confirmed. The trocars are removed and incisions closed and dressed.
Percutaneous
After the patient is anesthetized, ground pads are applied to the patient’s thighs and, using one of three image guidance techniques (ultrasound, Computed Tomography (CT) or Magnetic Resonance (MR)), a radiofrequency needle electrode is passed percutaneously through the liver and into the tumor to be treated. Radiofrequency energy is then delivered to ensure adequate tumor necrosis and tumor-free margins. The number of ablative passes will depend on the number of tumors to be treated and the size of the tumors treated. The needle tract within the liver is usually embolized or cauterized with the ablation needle prior to its removal to minimize risk of bleeding.
After the patient is anesthetized, ground pads are applied to the patient’s thighs and, using one of three image guidance techniques (ultrasound, Computed Tomography (CT) or Magnetic Resonance (MR)), a radiofrequency needle electrode is passed percutaneously through the liver and into the tumor to be treated. Radiofrequency energy is then delivered to ensure adequate tumor necrosis and tumor-free margins. The number of ablative passes will depend on the number of tumors to be treated and the size of the tumors treated. The needle tract within the liver is usually embolized or cauterized with the ablation needle prior to its removal to minimize risk of bleeding.
Covered Indications
RFA utilizes heat derived from radiofrequency energy to treat primary or secondary hepatic tumors. It is indicated for patients whose disease may be deemed unresectable by location or number of tumors, who have comorbid disease that makes them poor surgical candidates, or who refuse hepatic resection.
Limitations of Both Ablation Procedures
For patients having multiple hepatic lesions, Medicare would not expect such procedures to be medically necessary unless improved health outcomes are anticipated via appropriate documentation in the medical record.
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
- Safe and effective.
- Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
- Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
- Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
- Furnished in a setting appropriate to the patient’s medical needs and condition.
- Ordered and furnished by qualified personnel.
- One that meets, but does not exceed, the patient’s medical need.
- At least as beneficial as an existing and available medically appropriate alternative.
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.
12X, 13X, 83X, 85X
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: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all the CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Claims Processing Manual, for further guidance.
036X, 071X
CPT/HCPCS Codes
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Note:
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Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
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47370©
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Laparo ablate liver tumor rf
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47371©
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Laparo ablate liver cryosurg
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47380©
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Open ablate liver tumor rf
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47381©
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Open ablate liver tumor cryo
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47382©
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Percut ablate liver rf
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ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS codes 47370, 47371, 47380, 47381 and 47382:
Covered for:
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155.0
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Malignant neoplasm of liver, primary
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155.1
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Malignant neoplasm of intrahepatic bile ducts
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155.2
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Malignant neoplasm of liver, not specified as primary or secondary
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197.7
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Secondary malignant neoplasm of liver
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211.5
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Benign neoplasm of liver and biliary passages
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235.3
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Neoplasm of uncertain behavior, liver and biliary passages
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239.0
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Neoplasm of unspecified nature, digestive system
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Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
Diagnoses That Support Medical Necessity
N/A
ICD-9-CM Codes That DO NOT Support Medical Necessity
N/A
Diagnoses That DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.
Documentation Requirements
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
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