* 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 who are 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, 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).
This medical policy is not applicable to Radiofrequency Ablation of Tumors.
POLICY
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.
MEDICAL APPROPRIATENESS
Microwave tumor ablation is considered medically appropriate if ALL of the following are met:
Treatment is indicated for ANY ONE of the following conditions:
Primary or metastatic hepatic tumors as indicated by ALL of the following:
The tumor is unresectable due to location of lesion[s] and/or comorbid conditions
A single tumor of 5 cm or less or up to 3 nodules less than 3 cm each
Primary or metastatic lung tumors as indicated by ALL of the following:
The tumor is unresectable due to location of lesion and/or comorbid conditions
A single tumor of 3 cm or less
IMPORTANT REMINDERS
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 or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
ADDITIONAL INFORMATION
There is insufficient evidence to determine health outcomes with the use of microwave tumor ablation in other conditions.
SOURCES
BlueCross BlueShield Association. Evidence Positioning System. (11:2022). Microwave tumor ablation (7.01.133). Retrieved February 13, 2023 from https://www.bcbsaoca.com/eps/ (102 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)
Macchi, M., Belfiore, M.P., Floridi, C., Serra, N., Belfiore, G., Carmignani, L., et al. (2017). Radiofrequency versus microwave ablation for treatment of the lung tumours: LUMIRA (lung microwave radiofrequency) randomized trial. Medical Oncology, 34 (5), 96. Abstract retrieved April 2, 2021 from PubMed database.
Meijerink, M., Puijk, R.S., van Tilborg., A., Henningsen, K., Fernandez, L., Neyt, M., et al. (2018). Radiofrequency and microwave ablation compared to systemic chemotherapy and to partial hepatectomy in the treatment of colorectal liver metastases: A systematic review and meta-analysis. Cardiovascular and Interventional Radiology, 41 (8), 1189–1204. (Level 1 evidence)
Meng M., Han X., Li W., Huang G., Ni Y., Wang J., et al. (2021). CT-guided microwave ablation in patients with lung metastases from breast cancer. Thoracic Cancer, 12 (24), 3380-3386. (Level 4 evidence-
National Comprehensive Cancer Network. (2022, December). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Non-small cell lung cancer (V.1.2023). Retrieved February 13, 2023 from the National Comprehensive Cancer Network.
National Comprehensive Cancer Network. (2023, January). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Colon cancer (V.3.2022). Retrieved February 13, 2023 from the National Comprehensive Cancer Network.
National Comprehensive Cancer Network. (2023, January). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Hepatobiliary cancers (V.5.2022). Retrieved February 13, 2023 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. (2016, April). Microwave ablation for treating liver metastases. Retrieved May 25, 2016 from www.nice.org.uk/guidance/ipg553.
National Institute for Health and Clinical Excellence. (2022, February). Microwave ablation for primary or metastatic cancer in the lung. Retrieved February 16, 2022 from www.nice.org.
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)
Yang, G., Xiong, Y., Sun, J., Wang, G., Li, W., Tang, T., et al. (2020). The efficacy of microwave ablation versus liver resection in the treatment of hepatocellular carcinoma and liver metastases: A systematic review and meta-analysis. International Journal of Surgery, 5 (77), 85-93. Abstract retrieved May 13, 2020 from PubMed database.
ORIGINAL EFFECTIVE DATE: 7/14/2012
MOST RECENT REVIEW DATE: 4/13/2023
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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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