This policy version was replaced June 27, 2022. To find the newest version, go to https://www.bluecrossmn.com/providers/medical-policy-and-utilization-management, read and accept the Blue Cross Medical Policy Statement, then select “Blue Cross and Blue Shield of Minnesota Medical Policies.” This will bring up the Medical Policy search screen. Enter the policy number without the version number (last 3 digits).
Microwave ablation (MWA) destroys tumors and soft tissue by using microwave energy to create thermal coagulation and localized tissue necrosis. A single microwave antenna or multiple antennas connected to a generator are inserted directly into the tumor or tissue to be ablated, and energy from the antennas generates friction and heat. MWA may be performed as an open procedure, laparoscopically, percutaneously, or thoracoscopically under image guidance (e.g., ultrasound, computed tomography [CT] or magnetic resonance imaging [MRI]) with sedation, or local or general anesthesia. MWA has been investigated for ablation of tumors and tissue for the treatment of many conditions including: hepatocellular carcinoma, colorectal cancer metastatic to the liver, renal cell carcinoma, renal hamartoma, adrenal malignant carcinoma, non-small cell lung cancer, intrahepatic primary cholangiocarcinoma, breast tumors, abdominal tumors, and other tumors not amenable to resection. This technique may also be referred to as microwave coagulation therapy.
Proposed advantages of MWA include improved local control and benefits common to any minimally invasive procedure (e.g., preserving normal organ tissue, decreasing morbidity, decreasing length of hospitalization). Potential complications of the procedure include those caused by heat damage to normal tissue adjacent to the tumor (e.g., intestinal damage during MWA of the kidney or liver), structural damage along the probe track (e.g., pneumothorax as a consequence of procedures on the lung), liver enzyme elevation, liver abscess, ascites, pleural effusion, diaphragm injury, and secondary tumors, if cancerous cells are seeded during probe removal.
Several MWA devices have been cleared for marketing by the U.S. Food and Drug Administration (FDA) through the 510(k) process. Covidien's Evident Microwave Ablation System has 510(k) clearance for soft tissue ablation of non-resectable liver tumors. The following devices have 510(k) clearance for MWA of (unspecified) soft tissue:
This policy does not address MWA for the treatment of splenomegaly, ulcers or as a surgical coagulation tool.
I. Microwave ablation may be considered MEDICALLY NECESSARY AND APPROPRIATE for the following indications:
II. Microwave ablation is considered EXPERIMENTAL/INVESTIGATIVE for treatment of all other primary and metastatic tumors including, but not limited to, the following:
No additional statements.
Blue Cross and Blue Shield of Minnesota medical policies apply generally to all Blue Cross and Blue Plus plans and products. Benefit plans vary in coverage and some plans may not provide coverage for certain services addressed in the medical policies. When determining coverage, reference the member’s specific benefit plan, including exclusions and limitations.
Medicaid products may provide different coverage for certain services, which may be addressed in different policies. For Minnesota Health Care Program (MHCP) policies, please consult the MHCP Provider Manual website.
Medicare products may provide different coverage for certain services, which may be addressed in different policies. For Medicare National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and/or Local Coverage Articles, please consult CMS, National Government Services, or CGS websites.
Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met.
Blue Cross and Blue Shield of Minnesota reserves the right to revise, update and/or add to its medical policies at any time without notice. Codes listed on this policy are included for informational purposes only and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement.
These guidelines are the proprietary information of Blue Cross and Blue Shield of Minnesota. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Acknowledgements:
CPT® codes copyright American Medical Association® 2022. All rights reserved.
CDT codes copyright American Dental Association® 2022. All rights reserved.
