BlueCross BlueShield of Tennessee Medical Policy Manual

Radiofrequency Ablation of Tumors

DESCRIPTION

Radiofrequency ablation (RFA) involves the insertion of an electrode into the center of the tumor using a percutaneous, intraoperative or laparoscopic approach. RFA is guided by ultrasound (US) or computed tomography (CT). The tissue absorbs the radiofrequency energy emanating from the non-insulated part of the electrode. This process creates extreme heat, leading to coagulative necrosis. The goal is to destroy the entire area of the tumor, plus a margin of normal tissue, to control local disease, relieve symptoms and prolong survival.

POLICY

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

Examples of devices used for radiofrequency ablation include: Radiofrequency Interstitial Tissue Ablation (RITA®) and Radiotherapeutics®.

Well-designed, randomized, controlled trials with long-term follow-up are not available to determine long-term benefits of radiofrequency ablation for the treatment of certain types of cancers compared to alternative treatments.

SOURCES 

American College of Chest Physicians. (2013). Treatment of stage I and II non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of chest Physicians evidence-based clinical practice guidelines. Retrieved April 6, 2017 from the National Guideline Clearinghouse (NGC: 009880).

American College of Radiology. (2013). Appropriateness Criteria® early stage non-small cell lung cancer. Retrieved June 3, 2015 from http://www.guideline.gov.  

American College of Radiology. (2015). Appropriateness Criteria® radiologic management of hepatic malignancy. Retrieved April 2, 2018 from http://www.guideline.gov.

BlueCross BlueShield Association. Medical Policy Reference Manual. (9:2017). Radiofrequency ablation of miscellaneous solid tumors excluding liver tumors (7.01.95). Retrieved April 2, 2018 from BlueWeb. (59 articles and/or guidelines reviewed)

BlueCross BlueShield Association. Medical Policy Reference Manual. (8:2017). Radiofrequency ablation of primary or metastatic liver tumors (7.01.91). Retrieved April 2, 2018 from BlueWeb. (59 articles and/or guidelines reviewed)

Dong, J., Li, W., Zeng, Q., Li, S., Gong, X., Shen, L., et al. (2015). CT-guided percutaneous step-by-step radiofrequency ablation for the treatment of carcinoma in the caudate lobe. Medicine, 94 (39), e1594.

Du, S., Ni, J., Weng, L., Ma, F., Li, S., Wang, W., et al. (2015). Aggressive locoregional treatment improves the outcome of liver metastases from Grade 3 gastroenteropancreatic neuroendocrine tumors. Medicine, 94 (34), e1429.

Han, Y., Yan, D., Xu, F., Li, X., & Cai, J.Q. (2016). Radiofrequency ablation versus liver resection for colorectal cancer liver metastasis: an updated systematic review and meta-analysis. Chinese Medical Journal, 129 (24), 2983-2990. (Level 1 evidence)

Mauri, G., Sconfienza, L., Pescatori, L., Fedeli, M, Ali, M., Di Leo, G., & Sardanelli, F. (2017). Technical success, technique efficacy and complications of minimally-invasive imaging-guided percutaneous ablation procedures of breast cancer: a systematic review and meta-analysis. European Radiology, 2017 Jan 3. [Epub ahead of print].

National Comprehensive Cancer Network. (2018, February). NCCN clinical practice guidelines in oncology®. Hepatobiliary cancers (V.1.2018). Retrieved April 2, 2018 from https://www.nccn.org.

National Comprehensive Cancer Network. (2018, February). NCCN clinical practice guidelines in oncology®. Kidney cancer (V.3.2018). Retrieved April 2, 2018 from https://www.nccn.org

National Comprehensive Cancer Network. (2018, February). NCCN clinical practice guidelines in oncology®. Non-small cell lung cancer (V.3.2018). Retrieved April 2, 2018 from https://www.nccn.org.

National Comprehensive Cancer Network. (2018, March). NCCN clinical practice guidelines in oncology®. Bone cancer (V.2.2018). Retrieved April 2, 2018 from https://www.nccn.org.

National Comprehensive Cancer Network. (2018, March). NCCN clinical practice guidelines in oncology®. Colon cancer (V.2.2018). Retrieved April 2, 2018 from https://www.nccn.org.

National Comprehensive Cancer Network. (2018, March). NCCN clinical practice guidelines in oncology®. Neuroendocrine tumors (V.1.2018). Retrieved April 2, 2018 from https://www.nccn.org.

National Institute for Health and Clinical Excellence. (2003, July). Radiofrequency ablation of hepatocellular carcinoma. Retrieved April 10, 2017 from http://www.nice.org.

National Institute for Health and Clinical Excellence. (2009, December). Radiofrequency ablation for colorectal liver metastases. Retrieved April 10, 2017 from http://www.nice.org.

National Institute for Health and Clinical Excellence. (2010, April). Interventional procedure guidance. Percutaneous radiofrequency ablation for primary or secondary lung cancers. Retrieved March 8, 2011 from http://www.nice.org.

National Institute for Health and Clinical Excellence. (2010, July). Percutaneous radiofrequency ablation for renal cancer. Retrieved April 10, 2017 from http://www.nice.org.

National Institute for Health and Clinical Excellence. (2016, June). Ultrasound-guided percutaneous radiofrequency ablation for benign thyroid nodules. Retrieved April 10, 2017 from http://www.nice.org.

Ruers, T., Van Coevorden, F., Punt, C., Pierie, J., Borel-Rinkes, I., Ledermann, J., et al. (2017). Local treatment of unresectable colorectal liver metastases: results of a randomized phase II trial. Journal of the National Cancer Institute, 2017 Sep 1, 109 (9). Abstract retrieved April 10, 2017 from PubMed database.

Stone, B., Mangona, V., Johnson, M., Ye, H., & Grills, I. (2015). Changes in pulmonary function following image-guided stereotactic lung radiotherapy. Journal of Thoracic Oncology, 10 (12), 1762-1769. (Level 4 evidence)

U. S. Food and Drug Administration. (2004, April). Center for Devices and Radiological Health. Pre-market Notification Database K040989 (RITA® System). Retrieved March 20, 2007 from http://www.fda.gov.

U. S. Food and Drug Administration. (2008, September). Center for Devices and Radiological Health. Alerts and Notices (Medical Devices). FDA public health notification: Radiofrequency ablation of lung tumors - clarification of regulatory status. Retrieved January 21, 2011 from http://www.fda.gov.

ORIGINAL EFFECTIVE DATE:  6/1/2000

MOST RECENT REVIEW DATE:  5/10/2018

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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