Osteolytic bone metastases
Radiofrequency ablation may be considered medically necessary to palliate pain in individuals with osteolytic bone metastases who have failed or are poor candidates for standard treatments such as radiation or opioids.
Osteoid osteomas
Radiofrequency ablation may be considered medically necessary to treat osteoid osteomas that cannot be managed successfully with medical treatment.
Renal cell carcinoma
Radiofrequency ablation may be considered medically necessary to treat localized renal cell carcinoma that is no more than 4 cm in size when criteria 1 and 2 are met:
When it is necessary to preserve kidney function in individuals with significantly impaired renal function (ie, the individual has 1 kidney or renal insufficiency defined by a glomerular filtration rate of <60 mL/min/m2); When the standard surgical approach (ie, resection of renal tissue) is likely to worsen existing kidney function substantially; OR When the individual is not considered a surgical candidate. Non-small-cell lung cancer Radiofrequency ablation may be considered medically necessary to treat an isolated peripheral non-small-cell lung cancer lesion that is no more than 3 cm in size when criteria 1 and 2 are met: When surgical resection or radiotherapy with curative intent is considered appropriate based on stage of disease, however, medical comorbidity renders the individual unfit for those interventions; When the tumor is located at least 1 cm from the trachea, main bronchi, esophagus, aorta, aortic arch branches, pulmonary artery, and the heart. Nonpulmonary tumor(s) metastatic to the lung Radiofrequency ablation may be considered medically necessary to treat malignant nonpulmonary tumor(s) metastatic to the lung that are no more than 3 cm in size when criteria 1 and 2 are met: When it is necessary to preserve lung function because surgical resection or radiotherapy is likely to worsen pulmonary status substantially; OR When the individual is not considered a surgical candidate; When there is no evidence of extrapulmonary metastases; AND the tumor is located at least 1 cm from the trachea, main bronchi, esophagus, aorta, aortic arch branches, pulmonary artery, and the heart. (See the Policy Guidelines section for additional criteria.) Radiofrequency ablation is considered investigational as a technique for ablation of: breast tumors; lung cancer not meeting the criteria above; renal cell cancer not meeting the criteria above; osteoid osteomas that can be managed with medical treatment; painful bony metastases as initial treatment; and all other tumors outside the liver including, but not limited to, the head and neck, thyroid, pancreas, adrenal gland, ovary, and pelvic/abdominal metastases of unspecified origin.
