BlueCross BlueShield of Tennessee Medical Policy Manual

Cryosurgical Ablation of Miscellaneous Solid Tumors (e.g., Liver, Lung, Pancreas and Breast)

DESCRIPTION

Cryosurgical ablation (cryoablation or cryosurgery) involves exposing tissues to extreme cold to produce well-demarcated areas of cell injury and destruction. Cryosurgical ablation may be performed as an open surgical technique, percutaneously, or laparoscopically with ultrasound, magnetic resonance imaging (MRI), or computed tomography (CT) guidance.

POLICY

Policies with similar titles:

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

Scientific evidence addressing the long term outcomes of cryosurgical ablation is lacking. The available literature does not validate the safety and efficacy of this technology for the treatment of those diagnoses listed in the investigational statement.

SOURCES

American College of Radiology. (2015). ACR appropriateness criteria® radiologic management of hepatic malignancy. Retrieved July 7, 2016 from the National Guideline Clearinghouse (NGC: 010833).

BlueCross BlueShield Association. Medical Policy Reference Manual. (12:2015). Cryosurgical ablation of primary or metastatic liver tumors (7.01.75). Retrieved July 7, 2016 from BlueWeb. (29 articles and/or guidelines reviewed)

BlueCross BlueShield Association. Medical Policy Reference Manual. (8:2016). Cryosurgical ablation of miscellaneous solid tumors other than liver, prostate, or dermatologic tumors (7.01.92). Retrieved April 19, 2017 from BlueWeb. (49 articles and/or guidelines reviewed)

Keane, M., Pereira, S., Bramis, K., and Fusai, G. (March 2014) Systematic review of novel ablative methods in locally advanced pancreatic cancer. World Journal of Gastroenterology, 20(9): 2267–2278. (Level 1 evidence)

National Comprehensive Cancer Network. (2017). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Neuroendocrine tumors v.2.2017. Retrieved April 19, 2017 from the National Comprehensive Cancer Network.

National Comprehensive Cancer Network. (2017). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Colon Cancer v.2.2017. Retrieved April 19, 2017 from the National Comprehensive Cancer Network.

National Comprehensive Cancer Network. (2017). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Non-small cell lung cancer v.5.2017. Retrieved April 19, 2017 from the National Comprehensive Cancer Network.

National Comprehensive Cancer Network. (2017). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Hepatobiliary cancers v.1.2017. Retrieved April 19, 2017 from the National Comprehensive Cancer Network.

U.S. Food and Drug Administration. (1998, February). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K974320. Retrieved April 19, 2017 from https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K974320.

U.S. Food and Drug Administration. (2004, December). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K050347. Retrieved April 19, 2017 from https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K050347.

U.S. Food and Drug Administration. (2005, November). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K052530. Retrieved April 19, 2017 from https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K052530.

U.S. Food and Drug Administration. (2007, January). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K062896. Retrieved April 19, 2017 from https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K062896.

Winifred S. Hayes, Inc. Medical Technology Directory. (2015, December; last update search November 2016). Cryoablation for treatment of non-small cell lung cancer. Retrieved April 19, 2017 from www.Hayesinc.com/subscribers (40 articles and/or guidelines reviewed)

Wu, S., Hou, J., Ding, Y., Wu, F., Hu, Y., Jiang, Q., et al. (2015). Cryoablation versus radiofrequency ablation for hepatic malignancies: a systematic review and literature-based analysis. Medicine, 94 (49), e2252. Abstract retrieved July 7, 2016 from PubMed database.

ORIGINAL EFFECTIVE DATE:  3/1/2000

MOST RECENT REVIEW DATE:  5/11/2017

ID_BA

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

This document has been classified as public information.