Medical_Policy

Highmark Commercial Medical Policy - Pennsylvania

Medical Policy:	S-158-016
Topic:	Cryosurgical Ablation and Radiofrequency Ablation of Renal Tumors
Section:	Surgery
Effective Date:	January 23, 2017
Issue Date:	July 9, 2018
Last Reviewed:	June 2018

Cryosurgical ablation of the kidney (also called cryosurgery, cryotherapy, or cryodestruction) is the use of extreme cold to destroy cancer cells while preserving the surrounding healthy tissue.

Radiofrequency ablation (RFA) is a type of treatment for malignant renal tumors. This technique uses heat to destroy cancerous cells.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member’s benefit plan.

Cryosurgical ablation of renal cell carcinoma may be considered medically necessary for select individuals with small renal cell carcinoma less than or equal to 4cm when ANY ONE of the following criteria is met:

Individuals who are considered high-risk surgical candidates; or
Individuals with renal insufficiency, as defined by a glomerular filtration rate of less than or equal to 60 mL/min/m²; or
Individuals with a solitary kidney.

Cryosurgical ablation is considered not medically necessary for renal cell carcinoma that does not meet the above criteria.

Procedure Codes

50250, 50542, 50593

Radiofrequency ablation of renal cell carcinoma may be considered medically necessary for individuals with small renal tumors less than or equal to 4cm when ANY ONE of the following criteria is met:

Preservation of kidney function is necessary (i.e., the patient has 1 kidney or renal insufficiency defined by a glomerular filtration rate of less than 60 ml/min/m2) and standard surgical approach (i.e., resection of renal tissue) is likely to substantially worsen kidney function; or
The individual is not considered a surgical candidate.

Radiofrequency ablation is considered not medically necessary for renal cell carcinoma that does not meet the above criteria.

Procedure Codes

50542, 50592

Place of Service: Inpatient

The policy position applies to all commercial lines of business

Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Links

Link to Diagnosis Codes

Link to References

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:

Qualified sign language interpreters

Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:

Qualified interpreters

Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.