This Policy version was replaced on October 28, 2024. To find the newest version, go to https://www.bluecrossmn.com/providers/medical-management, select 'See Medical and Behavioral Health Policies', then 'Blue Cross and Blue Shield of Minnesota Medical and Behavioral Health Policies'. This will bring up the Medical Policy search screen. Enter the policy number without the version number (last three digits).
Percutaneous ultrasonic ablation of soft tissue, also known as percutaneous ultrasonic fasciotomy and percutaneous ultrasonic tenotomy, is a minimally invasive procedure used for the aspiration, fragmentation, and emulsification of soft tissue. It is associated with the surgical treatment of many conditions of the musculoskeletal system such as tendinopathy and fasciopathy.
These procedures are performed using devices known as the TX1™ Tissue Removal System and the TENEX Health TX™ System. The TX1™ and TENEX Health TX™ System use ultrasound technology to pinpoint the location of damaged tissue while using the device’s microtip to deliver ultrasonic energy, removing damaged tissue while stimulating a healing response. The TENEX Health TX™ System was cleared for marketing by the U.S. Food and Drug Administration (FDA) through the 510(k) process, recognizing this device as substantially equivalent to the predicate TX1™ Tissue Removal System device.
Percutaneous ultrasonic ablation of soft tissue is considered EXPERIMENTAL/INVESTIGATIVE for all indications, including but not limited to the following conditions, due to a lack of clinical evidence demonstrating an impact on improved health outcomes:
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® 2023. All rights reserved.
CDT codes copyright American Dental Association® 2023. All rights reserved.
