Covered without prior authorization (high confidence)
Documentation Required
No discrete 'Documentation Requirements' section is provided in this excerpt; however the policy implies that clinical documentation must support the specific selection criteria attached to each covered indication (examples below).
For renal mass cryoablation: documentation of tumor size (≤4 cm) and documentation that patient meets at least one criterion: high-risk surgical candidate; renal insufficiency with documented GFR ≤ 60 ml/min/1.73 m2; or solitary kidney
For adrenal gland metastases: documentation of adrenal lesion size (≤4 cm) (and typically documentation of metastatic disease and rationale for percutaneous ablation vs. surgery)
For pulmonary metastatic lesions: documentation that member is not a surgical candidate and that there are ≤ 6 lesions each < 4 cm in diameter
Key Coverage Criteria
C79.49 Secondary malignant neoplasm of other parts of nervous system
C79.51 Secondary malignant neoplasm of bone
C79.70 - C79.72 Secondary malignant neoplasm of adrenal gland
C79.82 Secondary malignant neoplasm of genital organs [prostate]
D02.20 - D02.22 Carcinoma in situ of bronchus and lung
Cryoablation for locally recurrent or metastatic bone and soft tissue tumors
For metastatic hemangiopericytoma to lung: documentation that member is not a surgical candidate and that there are < 5 metastases each < 3 cm in diameter
For painful bone metastases: documentation of pain attributable to metastasis and lesion size ≤ 2 cm