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)
Microwave tumor ablation is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Microwave tumor ablation for the treatment of other oncologic conditions is considered investigational.
Microwave tumor ablation is considered medically appropriate if ALL of the following are met:
Treatment is indicated for ANY ONE of the following conditions:
Liver metastases from colorectal cancer
Treatment is indicated for ANY ONE of the following:
Individual is a poor candidate for surgical resection
Used as a bridge for other curative therapies
Tumors are in a location accessible for ablation
Tumors are amenable to ablation
A margin of normal tissue is treated
Each lesion measures 5 cm or less
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits, or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
Microwave tumor ablation is supported by NCCN for hepatocellular carcinoma and liver metastases from colon cancer with a 2A rating. There is insufficient evidence to determine health outcomes with the use of microwave tumor ablation in other conditions.
BlueCross BlueShield Association. Medical Policy Reference Manual. (9:2017). Microwave Tumor Ablation (7.01.133). Retrieved June 20, 2018 from BlueWeb. (49 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.
National Comprehensive Cancer Network. (2018). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Hepatobiliary cancers (V.2.2018). Retrieved June 20, 2018 from the National Comprehensive Cancer Network.
National Comprehensive Cancer Network. (2018). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Neuroendocrine and adrenal tumors (V.2.2018). Retrieved June 20, 2018 from the National Comprehensive Cancer Network.
National Comprehensive Cancer Network. (2018). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Colon cancer (V.2.2018). Retrieved June 20, 2018 from the National Comprehensive Cancer Network.
National Institute for Health and Clinical Excellence. (2007, March). Microwave ablation of hepatocellular carcinoma. Retrieved May 25, 2016 from www.nice.org.uk/guidance/ipg214.
National Institute for Health and Clinical Excellence. (2013, November). Microwave ablation for treating primary lung cancer and metastases in the lung. Retrieved June 29, 2015 from www.nice.org.uk/ipg469.
National Institute for Health and Clinical Excellence. (2016, April). Microwave ablation for treating liver metastases. Retrieved May 25, 2016 from www.nice.org.uk/guidance/ipg553.
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)
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.
ORIGINAL EFFECTIVE DATE: 7/14/2012
MOST RECENT REVIEW DATE: 8/9/2018
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.