BlueCross BlueShield of Tennessee Medical Policy Manual

Cryosurgical Ablation of Solid Tumors

DESCRIPTION

Cryosurgical ablation (cryoablation, cryotherapy 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, laparoscopically, or percutaneously with ultrasound, magnetic resonance imaging (MRI), or computed tomography (CT) guidance.

Potential complications of cryosurgery include those caused by hypothermic damage to normal tissue adjacent to the tumor, structural damage along the probe track, and secondary tumors if cancerous cells are seeded during probe removal.

POLICY

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

The available literature does not support the safety and efficacy of cryosurgical ablation for the treatment of those diagnoses listed in the investigational statement.

SOURCES

American Urological Association. (2017). Renal mass and localized renal cancer: AUA guideline. Retrieved November 2, 2018 from www.auanet.org/guidelines.

BlueCross BlueShield Association. Evidence Positioning System. (7:2018). Cryosurgical ablation of primary or metastatic liver tumors (7.01.75). Retrieved November 2, 2018 from BlueWeb. (32 articles and/or guidelines reviewed)

BlueCross BlueShield Association. Evidence Positioning System. (7:2018). Cryosurgical ablation of miscellaneous solid tumors other than liver, prostate, or dermatologic tumors (7.01.92). Retrieved November 2, 2018 from https://www.evidencepositioningsystem.com/  (53 articles and/or guidelines reviewed)

BlueCross BlueShield Association. Evidence Positioning System. (8:2018). Whole gland cryoablation of prostate cancer (7.01.79). Retrieved November 2, 2018 from https://www.evidencepositioningsystem.com/  (48 articles and/or guidelines reviewed)

BlueCross BlueShield Association. Evidence Positioning System. (9:2018). Focal treatments for prostate cancer (8.01.61). Retrieved November 2, 2018 from https://www.evidencepositioningsystem.com/.  (61 articles and/or guidelines reviewed)

National Comprehensive Cancer Network. (2018, August). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Bone cancers V.1.2019. Retrieved November 2, 2018 from the National Comprehensive Cancer Network.

National Comprehensive Cancer Network. (2018, October). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Colon cancer V.4.2018. Retrieved November 2, 2018 from the National Comprehensive Cancer Network.

National Comprehensive Cancer Network. (2018, October). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Non-small cell lung cancer V.1.2019. Retrieved November 2, 2018 from the National Comprehensive Cancer Network.

National Comprehensive Cancer Network. (2018, October). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Hepatobiliary cancers V.4.2018. Retrieved November 2, 2018 from the National Comprehensive Cancer Network.

National Comprehensive Cancer Network. (2018, September). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Neuroendocrine tumors V.3.2018. Retrieved November 2, 2018 from the National Comprehensive Cancer Network.

National Comprehensive Cancer Network. (2018, September). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Kidney cancer V.2.2019. Retrieved November 2, 2018 from the National Comprehensive Cancer Network.

ORIGINAL EFFECTIVE DATE:  3/1/2000

MOST RECENT REVIEW DATE:  12/13/2018

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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