BlueCross BlueShield of Tennessee Medical Policy Manual

Microwave Ablation for Oncologic Tumors

* This is not all inclusive for areas treated and may be billed with more than the above codes.

DESCRIPTION

Microwave ablation (MWA) is a technique to destroy tumors and soft tissue using microwave energy to create thermal coagulation and localized tissue necrosis.  MWA is used to treat cancerous tumors not amenable to resection or to treat individuals ineligible for surgery due to age, comorbidities or poor general health.  MWA may be performed as an open procedure, laparoscopically, percutaneously or thoracoscopically under image guidance (e.g., ultrasound, computed tomography, magnetic resonance imaging) with sedation, or local or general anesthesia.

Note:  Transurethral Microwave Therapy (TUMT) is a different procedure used to treat urinary symptoms caused by an enlarged prostate. TUMT is addressed in an MCG; Transurethral Microwave Therapy (TUMT) ACG: A-0258 (AC)

POLICY

MEDICAL APPROPRIATENESS  

IMPORTANT REMINDERS

ADDITIONAL INFORMATION 

Microwave tumor ablation is supported by NCCN for hepatocellular carcinoma and liver metastases from colon cancer and neuroendocrine tumors.  There is insufficient evidence to determine health outcomes with the use of microwave tumor ablation in other conditions.

SOURCES

Agency for Healthcare Research and Quality. Effective Health Care Program Comparative Effectiveness Review Number 114. (2013). Local therapies for unresectable primary hepatocellular carcinoma. Retrieved May 26, 2016 from www.ahrq.gov.

Agency for Healthcare Research and Quality. Effective Health Care Program Comparative Effectiveness Review Number 93 (2012) Local hepatic therapies for metastases to the liver from unresectable colorectal cancer. Retrieved June 26, 2017 from www.ahrq.gov.

Agency for Healthcare Research and Quality. Effective Health Care Program Comparative Effectiveness Review Number 167 (2016) Management of renal masses and localized renal cancer. Retrieved June 26, 2017 from www.ahrq.gov.

American College of Radiology. (2015). ACR appropriateness criteria® radiologic management of hepatic malignancy. Retrieved May 27, 2016 from the National Guideline Clearinghouse (NGC:010833).

BlueCross BlueShield Association. Medical Policy Reference Manual. (9:2016). Microwave Tumor Ablation (7.01.133). Retrieved June 26, 2017 from BlueWeb. (47 articles and/or guidelines reviewed)

Chinnaratha, M., Chuang, M., Fraser, R., Woodman, R., & Wigg, A. (2016). Percutaneous thermal ablation for primary hepatocellular carcinoma: a systematic review and meta-analysis. Journal of Gastroenterology and Hepatology, 31 (2), 294-301. Abstract retrieved May 27, 2016 from PubMed database.

Facciorusso, A., DiMaso, M. & Muscatiello, N. (2016). Microwave ablation versus radiofrequency ablation for the treatment of hepatocellular carcinoma: a systematic review and meta-analysis. International Journal of Hyperthermia, 21, 1-6. Abstract retrieved May 27, 2016 from PubMed database.

Huo, Y. & Eslick, G. (2015). Microwave ablation compared to radiofrequency ablation for hepatic lesions: a meta-analysis. Journal of Vascular and Interventional Radiology, 26, 1139-1146. (Level 1 evidence)

Li, M., Yu, X., Liang, P., Dong, B., & Liu, F. (2015). Ultrasound-guided percutaneous microwave ablation for hepatic malignancy adjacent to the gallbladder. International Journal of Hyperthermia, 2015 (Jun), 1-9.

Mainini, A., Monaco, C., Pescatori, L., De Angelis, C., Sardanelli, F., Sconfienza, L., et. al. (2016, October) Image-guided thermal ablation of benign thyroid nodules. Journal of Ultrasound, 20(1),11-22. Abstract retrieved June 27, 2017 from PubMed database.

National Comprehensive Cancer Network. (2017, June). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Neuroendocrine tumors (V.3.2017). Retrieved June 26, 2017, 2017 from http://www.nccn.org.

National Comprehensive Cancer Network. (2017, March). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Colon cancer (V.2.2017). Retrieved June 26, 2017 from https://www.nccn.org.

National Comprehensive Cancer Network. (2017, May). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Hepatobiliary cancers (V.2.2017). Retrieved June 26, 2017 from http://www.nccn.org.

National Institute for Health and Clinical Excellence. (2007, March). Procedural guidance: Microwave ablation of hepatocellular carcinoma. Retrieved May 25, 2016 from http://www.nice.org.

National Institute for Health and Clinical Excellence. (2013, November). Procedural guidance: Microwave ablation for treating primary lung cancer and metastases in the lung. Retrieved June 29, 2015 from http://www.nice.org.

National Institute for Health and Clinical Excellence. (2016, April). Procedural guidance: Microwave ablation for treating liver metastases. Retrieved May 25, 2016 from http://www.nice.org.

Rocco, B., Albo, G., Ferreira, R., Spinelli, M., Cozzi, G., et. al. (2011) Recent advances in the surgical treatment of benign prostatic hyperplasia. Therapeutic Advances in Urology, 3(6), 263–272. (Level 5 evidence)

Sag, A., Selcukbiricik, F., & Mandel, N. (2016). Evidence-based medical oncology and interventional radiology paradigms for liver-dominant colorectal cancer metastases. World Journal of Gastroenterology, 22 (11), 3127-3149. (Level 2 evidence)

Splatt, A. & Steinke, K. (2015). Major complications of high-energy microwave ablation for percutaneous CT-guided treatment of lung malignancies: single-centre experience after 4 years. Journal of Medical Imaging and Radiation Oncology, 59 (5), 609-616. Abstract retrieved May 27, 2016 from PubMed database.

U. S. Food and Drug Administration. (2008, November). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K072687. Retrieved March 15, 2012 from http://www.accessdata.fda.gov.

Winifred S. Hayes, Inc. Clinical Research Response (2016, July) Microwave Tumor Ablation. Retrieved June 26, 2017 from www.Hayesinc.com.

ORIGINAL EFFECTIVE DATE:  7/14/2012

MOST RECENT REVIEW DATE:  8/10/2017

ID_BT

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.

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