BlueCross and BlueShield of Montana Medical Policy/Codes
Radiofrequency Ablation (RFA) of Solid Tumors (Excluding Pulmonary, Renal, and Liver)
Chapter: Radiology
Current Effective Date: November 26, 2013
Original Effective Date: March 05, 2010
Publish Date: November 26, 2013
Revised Dates: December 6, 2012; October 28, 2013
Description

In radiofrequency ablation (RFA), a probe is inserted into the center of a tumor and the non-insulated electrodes, which are shaped like prongs, are projected into the tumor; heat is then generated locally by a high-frequency, alternating current that flows from the electrodes. The local heat treats the tissue adjacent to the probe, resulting in a 3 cm to 5.5 cm sphere of dead tissue. The cells killed by RFA are not removed but are gradually replaced by fibrosis and scar tissue. If there is local recurrence, it occurs at the edge and, in some cases, may be retreated. Radiofrequency ablation may be performed percutaneously, laparoscopically, or as an open procedure.

Radiofrequency ablation (RFA) is being evaluated to treat various tumors, including inoperable tumors, or to treat patients ineligible for surgery due to age, presence of comorbidities, or poor general health. Goals of RFA may include 1) controlling local tumor growth and preventing recurrence; 2) palliating symptoms; and 3) extending survival duration for patients with certain tumors. The effective volume of RFA depends on the frequency and duration of applied current, local tissue characteristics, and probe configuration (e.g., single vs. multiple tips).

Potential complications associated with RFA include those caused by heat damage to normal tissue adjacent to the tumor (e.g., intestinal damage during RFA of kidney), structural damage along the probe track (e.g., pneumothorax as a consequence of procedures on the lung), or secondary tumors if cells seed during probe removal.

RFA was initially developed to treat inoperable tumors of the liver. Recently, reports have been published on use of RFA to treat renal cell carcinomas, breast tumors, pulmonary cancers (including primary and metastatic lung tumors), bone, and other tumors. For some of these, RFA is being investigated as an alternative to surgery for operable tumors. Well-established local or systemic treatment alternatives are available for each of these malignancies. The hypothesized advantages of RFA for these cancers include improved local control and those common to any minimally invasive procedure (e.g., preserving normal organ tissue, decreasing morbidity, decreasing length of hospitalization).

Breast tumors. There has been a trend in the treatment of small breast cancers from total mastectomy toward increasingly more conservative treatment options such as lumpectomy, with more acceptable cosmetic outcomes and preservation of the breast. The selection of surgical approach balances the patient’s desire for breast conservation and the need for tumor-free margins in resected tissue. Minimally invasive nonsurgical techniques such as RFA are appealing if they can produce local control and survival equivalent to breast-conserving surgical alternatives. Nonsurgical ablative techniques pose difficulties such as the inability to determine tumor size, complete tumor cell killing, and local recurrence. Additionally, RFA can cause burning of the skin or damage to muscle, possibly limiting use in patients with tumors near the skin or chest wall. (1)

Head and neck cancer. In patients with head and neck cancer with recurrent disease, surgical salvage attempts are poor in terms of local control, survival, and quality of life, and these recurrent tumors are often untreatable with standard salvage therapies. (2) Palliative chemotherapy or comfort measures may be offered. The safety and efficacy of RFA has been investigated as an option for palliative treatment in these situations.

Osteoid osteomas. Osteomas are the most common benign bone tumor, comprising 10–20% of benign and 2–3% of all bone tumors. (3) They are typically seen in children and young adults, with most diagnosed in patients between 5–20 years of age. Osteomas are most common in the lower extremity (usually the long bones, mainly the femur) and less common in the spine. These tumors typically have a characteristic clinical presentation and radiologic appearance, with pain, usually continuous and worse at night, and usually relieved by aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs). The natural history of the osteoid osteoma varies based upon its location, and although they rarely exceed 1.5 cm, may produce bone widening and deformation, limb length inequality, or angular deviations when near a growth plate. (3) When located in the spine, these lesions may lead to painful scoliosis or torticollis. (4) Sometimes, they heal spontaneously after 3–7 years.

Treatment options include medical management with NSAIDs, surgical excision (wide/en bloc excision or curetting), or the use of CT- or magnetic resonance imaging (MRI)-guided minimally invasive procedures including core drill excision, laser photocoagulation, or RFA. For many years, complete surgical excision was the classic treatment of osteomas, usually performed in patients with pain despite medical management. Complete surgical excision has several disadvantages. A substantial incision may be necessary and removal of a considerable amount of bone (especially in the neck of the femur), increases the need for bone grafting and/or internal fixation (which often necessitates a second procedure to remove the metal work). Other possible risks include avascular necrosis of the femoral head and postoperative pathologic fracture. In addition, surgical excision leads to a lengthier period of convalescence and postoperative immobilization. Anatomically inaccessible tumors may not be completely resectable and may recur. RFA of osteoid osteoma is done with a needle puncture, so no incision or sutures are needed, and patients may immediately walk on the treated extremity and return to daily activities as soon as the anesthetic effect wears off. (4) The risk of recurrence with RFA of an osteoma is 5–10%, and recurrent tumors can be retreated with RFA. (4) In general, RFA is not performed in many spinal osteomas because of possible thermal-related nerve damage.

Palliation for bone metastases. After lung and liver, bone is the third most common metastatic site and is relatively frequent among patients with primary malignancies of the breast, prostate, and lung. Bone metastases often cause osteolysis (bone breakdown), resulting in pain, fractures, decreased mobility, and reduced quality of life. External-beam irradiation often is the initial palliative therapy for osteolytic bone metastases. However, pain from bone metastases is refractory to radiation therapy in 20–30% of patients, while recurrent pain at previously irradiated sites may be ineligible for additional radiation due to risks of normal tissue damage. Other alternatives include hormonal therapy, radiopharmaceuticals such as strontium 89, and bisphosphonates. Less often, surgery or chemotherapy may be used for palliation, and intractable pain may require opioid medications. RFA has been investigated as another alternative for palliating pain from bone metastases.

Thyroid tumors. Surgical resection is the primary treatment choice for medically unresponsive, symptomatic benign thyroid tumors and thyroid carcinomas. However, techniques for ablation of thyroid tumors (e.g., RFA and microwave ablation) are being investigated.

Regulatory Issues

The U.S. Food and Drug Administration (FDA) issued a statement September 24, 2008 concerning the regulatory status of radiofrequency ablation. The FDA has cleared RFA devices for the general indication of soft tissue cutting, coagulation, and ablation by thermal coagulation necrosis. Under this general indication, RFA can be used as a tool to ablate tumors. Some RFA devices have been cleared for additional specific treatment indications, including partial or complete ablation of nonresectable liver lesions and palliation of pain associated with metastatic lesions involving bone.

Policy

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coverage

Radiofrequency ablation of osteoid osteomas or bony metastases may be considered medically necessary only when determined to be indicated by the treating physician for the following:

  • as palliative treatment of medically or surgically inoperable tumor(s), and/or
  • for patients who have failed or are a poor candidate for standard treatment such as surgical intervention, radiation, chemotherapy, or opioids.

Radiofrequency ablation may be considered medically necessary for treatment of primary and metastatic neoplasms when removal of the neoplasm may be curative but the patient has been determined by the treating physician to be unable to tolerate surgical resection.

Radiofrequency ablation is considered experimental, investigational and unproven for treatment of primary and metastatic neoplasms when the patient has been determined by the treating physician to be able to tolerate surgical resection.

Rationale

Breast Tumors

In 2010, Zhao and Wu conducted a systematic review of 38 studies on ablation techniques for breast cancer treatment published from 1994 to 2009. (5) Nine of the studies reviewed focused on RFA. The RFA studies included small breast tumors ranging in size from 0.5–7 cm. Tumor resection was performed immediately after ablation or up to 4 weeks after RFA. Complete coagulation necrosis rates of 76% to 100% were reported. The authors concluded RFA for breast cancer tumors is feasible, but further studies with longer follow-up on survival, tumor recurrence, and cosmetic outcomes are needed. In another 2010 review, Soukup and colleagues examined 17 studies on RFA for the treatment of breast tumors and found RFA is feasible and promising. However, while minimal adverse effects and complications occurred with breast RFA, the authors noted incomplete tumor ablation remains a concern. (6)

The following are examples of published studies on RFA for breast tumors. In 2012, Wilson and colleagues reported on 73 patients with invasive breast cancer who had a lumpectomy followed immediately by RFA to the lumpectomy bed. (7) The average breast tumor size was 1.0 + 0.54 cm (range 0.2-2.6 cm) and follow-up averaged 51 months. Disease-free survival was 100%, 92% and 86% at 1-, 3- and 5-years, respectively. One patient had tumor recurrence within 5 cm of the lumpectomy site and 3 patients had ipsilateral breast recurrences. In 2009, Imoto et al. reported on a series of 30 patients with T1N0 breast cancer who had sentinel node biopsy followed by RFA and breast-conserving surgery. (8) Twenty-six patients showed pathologic degenerative changes in tumor specimens with hematoxylin-eosin staining, and, in 24 of 26 cases, tumor cell viability was diagnosed as negative by nicotinamide adenine dinucleotide diaphorase staining. Two patients had skin burns and 7 had muscle burn related to RFA. In a 2008 2-stage Phase II clinical trial, patients with histologically confirmed noninflammatory and 3 cm or less ipsilateral breast tumor recurrence were treated with RFA followed by mastectomy. The study was ended early because of insufficient efficacy of the technique tested. (9) Authors of a small (n=10) series, in 2009, in which tumor size and fat content were analyzed, concluded that “the fat content of small primary breast cancer could serve as a ‘heat sink’ and should be considered as a preventing factor of complete local tumor destruction by RF thermal ablation.” (10) In a 2011 Phase I/II study, 49 patients were treated with RFA for breast tumors (mean size 1.70 cm) followed immediately with surgical resection. (11) Complete ablation was achieved in 30 patients (61%) by H&E staining and/or NADH diaphorase staining. Complete ablation increased to 83% in 24 patients with tumor size equal to or less than 2 cm in diameter. Adverse events related to the procedure included 3 muscle burns and 2 skin burns.

Studies on RFA for breast tumors have reported varied and incomplete ablation rates with concerns about post-ablation tumor cell viability. Long-term improvements in health outcomes have not been demonstrated. Additionally, available studies do not allow comparisons to conventional breast-conserving procedures. Further studies, with long-term follow-up, are needed to determine whether RFA for small breast cancers can provide local control and survival rates comparable to conventional breast-conserving treatment.

National Comprehensive Cancer Network (NCCN) Guidelines

NCCN guidelines do not address RFA in the management of breast cancer.

National Cancer Institute Clinical (NCI) Trials Database (PDQ®)

A search of the clinical trials database online at ClinicalTrials.gov identified no randomized studies on RFA for breast cancer. One non-randomized study will evaluate outcomes of RFA after breast cancer lumpectomy in 250 patients (NCT01153035) Two other ongoing Phase I/II NCI clinical trials were identified, including a pilot study of RFA to breast cancer lumpectomy sites to achieve negative margins without removing large volumes of tissue (NCT00571987) and a study of RFA after single-insertion image-guided vacuum-assisted biopsy to achieve negative margins in small breast cancers (<1.5 cm) (NCT00574301).

Head and Neck Cancer

A case series showed palliative CT-guided RFA provided subjective improvement with regard to pain, appearance, and function in 12 patients who had recurrent and advanced head and neck malignancies and were not candidates for radiation or surgery. (12) The procedure was deemed reasonably safe and feasible for this indication, but further study is needed.

A case series of RFA for 14 patients with recurrent advanced head and neck malignancies was reported by Brook et al. (2) Tumor targeting and electrode deployment was successful in all cases, and 4 of 6 patients who completed quality-of-life assessments showed improvement. Three major complications (in 27 applications, 11%) occurred 7 days to 2 weeks after the procedure. These included stroke, carotid artery rupture leading to death, and threatened carotid artery rupture with subsequent stroke. Retrospective analysis of intraprocedural CT scans revealed that the retractable electrodes were within 1 cm of the carotid artery during ablation in these cases.

In 2011, Owen et al. reported on RFA for 13 patients with recurrent and/or unresectable head and neck cancer who failed curative treatment. (13) Median patient survival was 127 days. While stable disease was reported in 8 patients after RFA, and quality-of-life scores improved, 3 deaths occurred (1 carotid hemorrhage and 2 strokes).

The evidence for RFA in head and neck tumors is limited to small case series. While RFA may have a role in palliation, complications are common and severe.

National Comprehensive Cancer Network (NCCN) Guidelines

NCCN guidelines do not address the use of RFA in head and neck cancer.

National Cancer Institute Clinical Trials Database (PDQ®)

A search of the NCI clinical trial database at ClinicalTrials.gov returned no current trials on the use of RFA in head and neck cancer.

Osteoid Tumors

In 2011, Rimondi and colleagues reported on a retrospective study of 557 patients treated with computed tomography (CT)-guided RFA as primary treatment for non-spinal osteoid osteomas. (14) All patients were followed for a mean of 3.5 years (0.5-9 years). Pain relief occurred in all 557 patients within the first week after RFA and continued in 533 patients (96%) who remained asymptomatic through their last follow-up. Pain recurrence occurred in 24 patients (4%). Complications occurred in 5 patients and included thrombophlebitis, a skin burn, a broken electrode and 2 procedures in which the RFA generator didn’t reach maximum temperature.

In 2003, Rosenthal and colleagues reported their experience over an 11-year period with 271 RFA procedures for osteoid osteomas in 263 patients. (15) Short-term outcome was evaluated to detect procedure-related problems; by this definition, all procedures were considered technically successful. Long-term clinical success data (defined as being free of pain without the necessity of additional procedures) were available in 126 patients, with a complete clinical success observed in 89%. For procedures performed as the initial treatment, the success rate was 91%.

In 2004, Cioni and colleagues reported on a case series of 38 patients with osteoid osteoma diagnosed clinically, as well as by radiography, scintigraphy, contrast-enhanced magnetic resonance imaging (MRI), and CT. A total of 30 of the 38 patients reported prompt pain relief. Six of the remaining 8 patients underwent successful retreatment, and 2 underwent surgical excision. (16)

Another case series reported primary success in 37 of 38 (97%) patients (age range: 5–43 years) who underwent CT-guided percutaneous RFA to treat clinically and radiologically suspected osteoid osteoma. (17) Lesions were located in the proximal femur (n=13), tibia (n=5), foot (n=5), spine and fibula (n=3 each), acetabulum and humerus (n=2 each), and in other sites (n=5). All patients experienced sufficient pain relief to permit resumption of normal activities within 24 hours of the procedure. During follow-up, ranging from 3–24 months, no major complications were reported.

While there are no randomized trials for this indication, uncontrolled studies have demonstrated RFA can provide adequate pain relief with minimal complications. Therefore, the use of RFA for the treatment of osteoid osteomas that cannot be successfully treated with medical treatment may be considered medically necessary.

National Institute for Clinical Excellence (NICE)

Guidance issued in 2004 indicates that “current evidence on the safety and efficacy of computed tomography (CT)-guided thermocoagulation of osteoid osteoma appears adequate to support its use, provided that the normal arrangements are in place for consent, audit and clinical governance.” (18)

Palliation of Pain from Bone Metastases

Goetz et al. (19) reported on an international study (n=43) conducted at 9 centers in which patients with painful osteolytic bone metastases were treated palliatively with radiofrequency ablation (RFA). The study’s primary outcome measure was the Brief Pain Inventory-Short Form, a validated scale from 0 for no pain to 10 for worst pain imaginable. Patient eligibility required baseline values of 4 or more from 2 or fewer painful sites. Thirty-nine (91%) of the patients had previously received opioids to control pain from the lesion(s) treated with RFA, and 32 (74%) had prior radiation therapy to the same lesion. Mean pain score at baseline was 7.9 (range: 4–10). At 4, 12, and 24 weeks after RFA, average pain scores decreased to 4.5, 3.0, and 1.4, respectively (all p<0.0005). Forty-one (95%) of the patients achieved a clinically significant improvement in pain scores, prospectively defined as a decrease of 2 units from baseline. Investigators also reported statistically significant (p=0.01) decreases in opioid use at weeks 8 (by 59%) and 12 (by 54%).

An earlier case series showed that palliative RFA provided significant pain relief in 9 of 10 (90%) patients with unresectable, osteolytic spine metastases who had no other treatment options. (20) Pain was reduced by an average of 74%; back pain-related disability was reduced by an average of 27%. Neurologic function was preserved in 9 patients and improved in 1. An additional small case series of 24 patients with painful metastatic bone tumors who experienced pain-alleviating effects with RFA supports the policy statement. (21)

Several additional case series reports have been published with similar conclusions. These uncontrolled studies included only a limited number of cases. However, the patient populations comprised individuals with limited or no treatment options, for whom short-term pain relief is an appropriate outcome. Therefore, the use of RFA as palliative therapy in patients with painful metastatic bone lesions may be considered medically necessary.

Because data were unavailable on use of RFA as initial therapy for pain from bone metastases, this indication remains investigational. Neither setting is addressed in the National Comprehensive Cancer Network (NCCN) guidelines for the treatment of bone cancers.

Thyroid Tumors

A case series of 94 elderly subjects with solid or mainly solid benign thyroid nodules was reported by an Italian center. (22) Thyroid nodule volume, compressive symptoms, and thyroid function were evaluated at baseline and 12 to 24 months after treatment. All thyroid nodules significantly decreased in size after RFA. Compressive symptoms improved in all patients and disappeared completely in 88% of patients. Hyperthyroidism resolved in most patients allowing methimazole therapy to be completely withdrawn in 79% of patients with pretoxic and toxic thyroid nodules (100% in pretoxic and 53% with toxic thyroid nodules). The authors observe that RFA is particularly attractive for elderly people for whom surgery and radioiodine therapy are often contraindicated or ineffective. A smaller series (n=33) also from Italy found similar outcomes in terms of reduction in compressive symptoms and improvement in thyroid function. (23) Hyperfunction was fully controlled in 24% of patients and partially reduced in the others.

In 2012, Huh and colleagues reported on 30 patients randomized to receive either 1 or 2 RFA sessions for the treatment of benign thyroid nodules. Significant volume reduction occurred in each group of 15 patients after RFA. (24) A single session of RFA was sufficient to reduce tumor volume and improve clinical symptoms in 12 patients (80%). Only 3 patients with nodules larger than 20 mL required an additional session of RFA. Baek et al. reported on a retrospective review of RFA for 1,543 benign thyroid nodules in 1,459 patients at 13 thyroid centers. (25) Forty-eight (3.3%) complications occurred and included 20 major complications: voice changes (n=15), brachial plexus injury (n=1), tumor rupture (n=3), and permanent hypothyroidism (n=1). Twenty-eight minor complications included: hematoma (n=15), skin burn (n=4), and vomiting (n=9). One patient experienced permanent hypothyroidism while another required surgery.

In 2012, the Korean Society of Thyroid Radiology (KSTR) developed consensus recommendations for RFA of thyroid tumors after a review of the literature found few controlled studies. (26) The KSTR recommendations indicate RFA may be appropriate for the treatment of benign thyroid nodules, inoperable thyroid nodules, and recurrent thyroid cancers in the operation bed and lymph nodes. The KSTR recommendations also indicate RFA should not be used for primary thyroid cancers or follicular neoplasms citing no evidence of treatment benefit.

The evidence for RFA in thyroid tumors is primarily limited to case series and uncontrolled studies. While RFA has been shown to reduce thyroid tumor volume and improve clinical symptoms, complications can be common and available evidence is insufficient to determine the impact of RFA on net health outcomes.

National Cancer Institute Clinical Trials Database (PDQ®)

A search of the National Cancer Institute (NCI) clinical trial database online at ClinicalTrials.gov returned no current trials on the use of RFA in thyroid tumors.

National Comprehensive Cancer Network (NCCN) Guidelines

NCCN guidelines for thyroid carcinoma indicate ablation techniques such as radiofrequency may be considered for palliative resection of symptomatic distant metastases that are causing symptoms (e.g., those in bone). (27) Ablation may also be considered for asymptomatic distant metastases when there is progressive disease, but observation is acceptable, given the lack of data regarding alteration in outcome.

Miscellaneous Neoplasms

One case series of 13 patients with adrenal neoplasms treated with RF ablation was identified. Eleven of the 13 lesions were treated successfully with RFA, defined by follow-up CT scans and normalization of preprocedural biochemical abnormalities. (28)

A single-arm, retrospective, paired-comparison study evaluated the short-term efficacy of RFA in relationship to pain and functional impact in patients with unresectable, painful soft tissue neoplasms recalcitrant to conventional therapies. (29) Patients had tumors located in a variety of sites including chest wall, pelvis, breast, perirectal, renal, aortocaval, retroperitoneal, and superficial soft tissues. All had exhausted conventional methods of palliation or experienced dose-limiting adverse effects from pain medication. Although not all Brief Pain Inventory scores were statistically significant, all mean scores trended down with increased time after ablation. Complications from RFA were minor or insignificant in all but 1 patient who had skin breakdown and infection of the ablated superficial tumor site.

Additional articles address the use of RFA in solid malignancies (4, 30) and in the pancreas. (31-33)

Preliminary results of endoscopic RFA of rectosigmoid tumors have been described in a paper by Vavra et al. Twelve patients were treated with the Endoblate RFA device, with 10 patients having surgical resection after ablation. (34) Histology of the resected specimens showed that, on average, 82% (range: 60-99%) of the tumor mass was destroyed in the ablation zone.

Stereotactic radiofrequency thermocoagulation for epileptogenic hypothalamic hamartomas is described in a retrospective analysis of a series of 25 patients with gelastic seizures (a rare type of seizure that involves a sudden burst of energy, usually in the form of laughing or crying). (35) Other seizure types were exhibited in 22 patients (88.0%), precocious puberty in 8 (32.0%), behavioral disorder in 10 (40.0%), and mental retardation/intellectual disability in 14 (56.0%). Gelastic seizures resolved in all but 2 patients. Complete seizure freedom was achieved in 19 patients (76.0%). These patients had disappearance of all seizure types and behavioral disorder and also demonstrated intellectual improvement.

Small case series on RFA for colorectal and rectal carcinoma have demonstrated a debulking role for RFA. (36, 37)

These case series do not allow comparison with available alternative treatments and further study is required.

Coding

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps. 

ICD-9 Codes

77.6, 85.20, 213.0, 213.1, 213.2, 213.3, 213.4, 213.5, 213.6, 213.7, 213.8, 213.9, 174.0, 174.1, 174.2, 174.3, 174.4, 174.5, 174.6, 174.8, 174.9, 195.0, 215.0

ICD-10 Codes

C50.011-C50.929, C76.0, C79.51, C79.52, D16.00-D16.9, 0HBT0ZZ, 0HBT3ZZ,  0HBT7ZZ,  0HBT8ZZ, 0HBTXZZ,  0HBU0ZZ,  0HBU3ZZ,  0HBU7ZZ,  0HBU8ZZ,  0HBUXZZ, 0HBY0ZZ,  0HBY3ZZ,  0HBY7ZZ,  0HBY8ZZ, 0HBYXZZ, 0P500ZZ, 0P503ZZ, 0P504ZZ, 0P510ZZ, 0P513ZZ, 0P514ZZ, 0P520ZZ, 0P523ZZ, 0P524ZZ, 0P550ZZ, 0P553ZZ, 0P554ZZ, 0P560ZZ, 0P563ZZ, 0P564ZZ, 0P570ZZ, 0P573ZZ, 0P574ZZ, 0P580ZZ, 0P583ZZ, 0P584ZZ, 0P590ZZ, 0P593ZZ, 0P594ZZ, 0P5B0ZZ, 0P5B3ZZ, 0P5B4ZZ, 0P5C0ZZ, 0P5C3ZZ, 0P5C4ZZ, 0P5D0ZZ, 0P5D3ZZ, 0P5D4ZZ, 0P5F0ZZ, 0P5F3ZZ, 0P5F4ZZ, 0P5G0ZZ, 0P5G3ZZ, 0P5G4ZZ, 0P5H0ZZ, 0P5H3ZZ, 0P5H4ZZ, 0P5J0ZZ, 0P5J3ZZ, 0P5J4ZZ, 0P5K0ZZ, 0P5K3ZZ, 0P5K4ZZ, 0P5L0ZZ, 0P5L3ZZ, 0P5L4ZZ, 0P5M0ZZ, 0P5M3ZZ, 0P5M4ZZ, 0P5N0ZZ, 0P5N3ZZ, 0P5N4ZZ, 0P5P0ZZ, 0P5P3ZZ, 0P5P4ZZ, 0P5Q0ZZ, 0P5Q3ZZ, 0P5Q4ZZ, 0P530ZZ, 0P533ZZ, 0P534ZZ, 0P540ZZ, 0P543ZZ, 0P544ZZ, 0P5R0ZZ, 0P5R3ZZ, 0P5R4ZZ, 0P5S0ZZ, 0P5S3ZZ, 0P5S4ZZ, 0P5T0ZZ, 0P5T3ZZ, 0P5T4ZZ, 0P5V0ZZ, 0P5V3ZZ, 0P5V4ZZ, 0Q560ZZ, 0Q563ZZ, 0Q564ZZ, 0Q570ZZ, 0Q573ZZ, 0Q574ZZ, 0Q580ZZ, 0Q583ZZ, 0Q584ZZ, 0Q590ZZ, 0Q593ZZ, 0Q594ZZ, 0Q5B0ZZ, 0Q5B3ZZ, 0Q5B4ZZ, 0Q5C0ZZ, 0Q5C3ZZ, 0Q5C4ZZ, 0Q5D0ZZ, 0Q5D3ZZ, 0Q5D4ZZ, 0Q5F0ZZ, 0Q5F3ZZ, 0Q5F4ZZ, 0Q5G0ZZ, 0Q5G3ZZ, 0Q5G4ZZ, 0Q5H0ZZ, 0Q5H3ZZ, 0Q5H4ZZ, 0Q5J0ZZ, 0Q5J3ZZ, 0Q5J4ZZ, 0Q5K0ZZ, 0Q5K3ZZ, 0Q5K4ZZ, 0Q5L0ZZ, 0Q5L3ZZ, 0Q5L4ZZ, 0Q5M0ZZ, 0Q5M3ZZ, 0Q5M4ZZ, 0Q5N0ZZ, 0Q5N3ZZ, 0Q5N4ZZ, 0Q5P0ZZ, 0Q5P3ZZ, 0Q5P4ZZ, 0Q500ZZ, 0Q503ZZ, 0Q504ZZ, 0Q510ZZ, 0Q513ZZ, 0Q514ZZ, 0Q520ZZ, 0Q523ZZ, 0Q524ZZ, 0Q530ZZ, 0Q533ZZ, 0Q534ZZ, 0Q540ZZ, 0Q543ZZ, 0Q544ZZ, 0Q550ZZ, 0Q553ZZ, 0Q554ZZ, 0Q5Q0ZZ, 0Q5Q3ZZ, 0Q5Q4ZZ, 0Q5R0ZZ, 0Q5R3ZZ, 0Q5R4ZZ, 0Q5S0ZZ, 0Q5S3ZZ, 0Q5S4ZZ

Procedural Codes: 20982, 76940
References
  1. Noguchi M. Is radiofrequency ablation treatment for small breast cancer ready for "prime time"? Breast Cancer Res Treat 2007; 106(3):307-14.
  2. Brook AL, Gold MM, Miller TS et al. CT-guided radiofrequency ablation in the palliative treatment of recurrent advanced head and neck malignancies. J Vasc Interv Radiol 2008; 19(5):725-35.
  3. Ghanem I. The management of osteoid osteoma: updates and controversies. Curr Opin Pediatr 2006; 18(1):36-41.
  4. Rosenthal DI. Radiofrequency treatment. Orthop Clin North Am 2006; 37(3):475-84, viii.
  5. Zhao Z, Wu F. Minimally-invasive thermal ablation of early-stage breast cancer: a systemic review. Eur J Surg Oncol 2010; 36(12):1149-55.
  6. Soukup B, Bismohun S, Reefy S et al. The evolving role of radiofrequency ablation therapy of breast lesions. Anticancer Res 2010; 30(9):3693-7.
  7. Wilson M, Korourian S, Boneti C et al. Long-term results of excision followed by radiofrequency ablation as the sole means of local therapy for breast cancer. Ann Surg Oncol 2012; 19(10):3192-8.
  8. Imoto S, Wada N, Sakemura N et al. Feasibility study on radiofrequency ablation followed by partial mastectomy for stage I breast cancer patients. Breast 2009; 18(2):130-4.
  9. Garbay JR, Mathieu MC, Lamuraglia M et al. Radiofrequency thermal ablation of breast cancer local recurrence: a phase II clinical trial. Ann Surg Oncol 2008; 15(11):3222-6.
  10. Athanassiou E, Sioutopoulou D, Vamvakopoulos N et al. The fat content of small primary breast cancer interferes with radiofrequency-induced thermal ablation. Eur Surg Res 2009; 42(1):54-8.
  11. Kinoshita T, Iwamoto E, Tsuda H et al. Radiofrequency ablation as local therapy for early breast carcinomas. Breast Cancer 2011; 18(1):10-7.
  12. Owen RP, Silver CE, Ravikumar TS et al. Techniques for radiofrequency ablation of head and neck tumors. Arch Otolaryngol Head Neck Surg 2004; 130(1):52-6.
  13. Owen RP, Khan SA, Negassa A et al. Radiofrequency ablation of advanced head and neck cancer. Arch Otolaryngol Head Neck Surg 2011; 137(5):493-8.
  14. Rimondi E, Mavrogenis AF, Rossi G et al. Radiofrequency ablation for non-spinal osteoid osteomas in 557 patients. Eur Radiol 2012; 22(1):181-8.
  15. Rosenthal DI, Hornicek FJ, Torriani M et al. Osteoid osteoma: percutaneous treatment with radiofrequency energy. Radiology 2003; 229(1):171-5.
  16. Cioni R, Armillotta N, Bargellini I et al. CT-guided radiofrequency ablation of osteoid osteoma: long-term results. Eur Radiol 2004; 14(7):1203-8.
  17. Martel J, Bueno A, Ortiz E. Percutaneous radiofrequency treatment of osteoid osteoma using cool-tip electrodes. Eur J Radiol 2005; 56(3):403-8.
  18. National Institute for Clinical Excellence (NICE). Computed tomography-guided thermocoagulation of osteoid osteoma. 2004. Available online at: www.nice.org.uk Last accessed September, 2012.
  19. Goetz MP, Callstrom MR, Charboneau JW et al. Percutaneous image-guided radiofrequency ablation of painful metastases involving bone: a multicenter study. J Clin Oncol 2004; 22(2):300-6.
  20. Gronemeyer DH, Schirp S, Gevargez A. Image-guided radiofrequency ablation of spinal tumors: preliminary experience with an expandable array electrode. Cancer J 2002; 8(1):33-9.
  21. Kojima H, Tanigawa N, Kariya S et al. Clinical assessment of percutaneous radiofrequency ablation for painful metastatic bone tumors. Cardiovasc Intervent Radiol 2006; 29(6):1022-6.
  22. Spiezia S, Garberoglio R, Milone F et al. Thyroid nodules and related symptoms are stably controlled two years after radiofrequency thermal ablation. Thyroid 2009; 19(3):219-25.
  23. Deandrea M, Limone P, Basso E et al. US-guided percutaneous radiofrequency thermal ablation for the treatment of solid benign hyperfunctioning or compressive thyroid nodules. Ultrasound Med Biol 2008; 34(5):784-91.
  24. Huh JY, Baek JH, Choi H et al. Symptomatic benign thyroid nodules: efficacy of additional radiofrequency ablation treatment session--prospective randomized study. Radiology 2012; 263(3):909-16.
  25. Baek JH, Lee JH, Sung JY et al. Complications encountered in the treatment of benign thyroid nodules with US-guided radiofrequency ablation: a multicenter study. Radiology 2012; 262(1):335-42.
  26. Na DG, Lee JH, Jung SL et al. Radiofrequency ablation of benign thyroid nodules and recurrent thyroid cancers: consensus statement and recommendations. Korean J Radiol 2012; 13(2):117-25.
  27. Thyroid Carcinoma. National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology, v3.2012. Available online at: www.nccn.org Last accessed September, 2012.
  28. Mayo-Smith WW, Dupuy DE. Adrenal neoplasms: CT-guided radiofrequency ablation--preliminary results. Radiology 2004; 231(1):225-30.
  29. Locklin JK, Mannes A, Berger A et al. Palliation of soft tissue cancer pain with radiofrequency ablation. J Support Oncol 2004; 2(5):439-45.
  30. Liapi E, Geschwind JF. Transcatheter and ablative therapeutic approaches for solid malignancies. J Clin Oncol 2007; 25(8):978-86.
  31. Spiliotis JD, Datsis AC, Michalopoulos NV et al. Radiofrequency ablation combined with palliative surgery may prolong survival of patients with advanced cancer of the pancreas. Langenbecks Arch Surg 2007; 392(1):55-60.
  32. Zou YP, Li WM, Zheng F et al. Intraoperative radiofrequency ablation combined with 125 iodine seed implantation for unresectable pancreatic cancer. World J Gastroenterol 2010; 16(40):5104-10.
  33. Cantore M, Girelli R, Mambrini A et al. Combined modality treatment for patients with locally advanced pancreatic adenocarcinoma. Br J Surg 2012; 99(8):1083-8.
  34. Vavra P, Dostalik J, Zacharoulis D et al. Endoscopic radiofrequency ablation in colorectal cancer: initial clinical results of a new bipolar radiofrequency ablation device. Dis Colon Rectum 2009; 52(2):355-8.
  35. Kameyama S, Murakami H, Masuda H et al. Minimally invasive magnetic resonance imaging-guided stereotactic radiofrequency thermocoagulation for epileptogenic hypothalamic hamartomas. Neurosurgery 2009; 65(3):438-49; discussion 49.
  36. Mylona S, Karagiannis G, Patsoura S et al. Palliative treatment of rectal carcinoma recurrence using radiofrequency ablation. Cardiovasc Intervent Radiol 2012; 35(4):875-82.
  37. Ripley RT, Gajdos C, Reppert AE et al. Sequential radiofrequency ablation and surgical debulking for unresectable colorectal carcinoma: Thermo-surgical ablation. J Surg Oncol 2012 [Epub ahead of print].
  38. Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2012 October) Surgery 7.01.95.
History
December 2012  Policy updated with literature review.  Policy statements changed to indicate medically necessary options for primary and metastatic pulmonary tumors.  Policy statements changed from Not Medically Necessary to Investigational.  References 12, 19, 29, 42, 50-53, 59, 62-63 added.  Other references deleted. 
November 2013 Policy formatting and language revised.  Title changed from "Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors" to "Radiofrequency Ablation (RFA) of Solid Tumors (Excluding Pulmonary, Renal, and Liver)".  Renal and pulmonary tumors moved to separate policies.  Removed CPT codes 32998, 50542, and 50592.
BCBSMT Home
®Registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. ®LIVE SMART. LIVE HEALTHY. is a registered mark of BCBSMT, an independent licensee of the Blue Cross and Blue Shield Association, serving the residents and businesses of Montana.
CPT codes, descriptions and material only are copyrighted by the American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS Restrictions Apply to Government Use. CPT only © American Medical Association.
Radiofrequency Ablation (RFA) of Solid Tumors (Excluding Pulmonary, Renal, and Liver)