Anthem Blue Cross Blue Shield of California policy
Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the Liver
Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the Liver is a public Anthem Blue Cross Blue Shield of California policy (policy CG-SURG-61). It lists 25 CPT or HCPCS codes, 24 of them on the Anthem Blue Cross Blue Shield of California prior authorization list. Not a coverage decision; the payer's own document governs.
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- Policy number
- CG-SURG-61
- Line of business
- Commercial
- Source
- www.anthem.com
Codes in this policy
The CPT and HCPCS codes the policy names. A policy can name a code it excludes. Prior authorization status is from the Anthem Blue Cross Blue Shield of California prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross Blue Shield of California policies |
|---|---|---|---|
| 0581T | On the list | Ablation, malignant breast tumor(s), percutaneous, cryotherapy, including imaging guidance when performed, unilateral | Policies naming 0581T |
| 0673T | On the list | Ablation, benign thyroid nodule(s), percutaneous, laser, including imaging guidance | Policies naming 0673T |
| 0970T | On the list | Ablation, benign breast tumor (e.g., fibroadenoma), percutaneous, laser, including imaging guidance when performed, each tumor | Policies naming 0970T |
| 0971T | On the list | Ablation, malignant breast tumor(s), percutaneous, laser, including imaging guidance when performed, unilateral | Policies naming 0971T |
| 19105 | On the list | Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma | Policies naming 19105 |
| 19499 | On the list | Unlisted procedure, breast [when specified as destruction of breast tissue by high intensity focused ultrasound] or [when specified as radiofrequency or microwave ablation or laser ablation of breast tumor(s)] or [when specified as catheter lavage of a mammary duct or fiberoptic ductoscopy] | Policies naming 19499 |
| 20982 | On the list | Ablation, bone tumor(s) (e.g., osteoid osteoma, metastasis) radiofrequency, percutaneous, including computed tomographic guidance | Policies naming 20982 |
| 20983 | On the list | Ablation therapy for reduction or eradication of 1 or more bone tumors (e.g., metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; cryoablation | Policies naming 20983 |
| 20999 | On the list | Unlisted procedure, musculoskeletal system, general [when specified as high intensity focused ultrasound for pain palliation for bone metastases] or [No specific code for surgery using Coblation technology] or [when specified as radiofrequency or pulsed radiofrequency treatment of trigger points] or [when specified as percutaneous ultrasonic ablation of soft tissue] or [when specified as harvesting and injection of bone marrow aspirate concentrate or harvesting or administration of stem cells for therapy to repair damaged cells or body tissues] | Policies naming 20999 |
| 32994 | On the list | Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, including imaging | Policies naming 32994 |
| 32998 | On the list | Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, radiofrequency, unilateral | Policies naming 32998 |
| 32999 | Not listed | Policies naming 32999 | |
| 48999 | On the list | Unlisted procedure, pancreas [when specified as cryosurgical or radiofrequency ablation of pancreas tumor(s)] | Policies naming 48999 |
| 50250 | On the list | Ablation, open, 1 or more renal mass lesion(s), cryosurgical, including intraoperative ultrasound, if performed | Policies naming 50250 |
| 50542 | On the list | Laparoscopy, surgical; ablation of renal mass lesion(s) | Policies naming 50542 |
| 50592 | On the list | Ablation, 1 or more renal tumor(s), percutaneous, unilateral, radiofrequency | Policies naming 50592 |
| 50593 | On the list | Ablation, renal tumor(s), unilateral, percutaneous, cryotherapy | Policies naming 50593 |
| 53850 | On the list | Transurethral destruction of prostate tissue; by microwave thermotherapy | Policies naming 53850 |
| 53852 | On the list | Transurethral destruction of prostate tissue; by radiofrequency thermotherapy | Policies naming 53852 |
| 55873 | On the list | Cryosurgical ablation of the prostate (includes ultrasonic guidance for interstitial cryosurgical probe placement) | Policies naming 55873 |
| 60660 | On the list | Ablation of 1 or more thyroid nodule(s), one lobe or the isthmus, percutaneous, including imaging guidance, radiofrequency | Policies naming 60660 |
| 60661 | On the list | Ablation of 1 or more thyroid nodule(s), additional lobe, percutaneous, including imaging guidance, radiofrequency | Policies naming 60661 |
| 60699 | On the list | Unlisted procedure, endocrine system [when specified as cryosurgical or radiofrequency ablation of thyroid or adrenal tumor(s)] or [when specified as image-guided focused ultrasound ablation for non-oncologic indications] or [when specified as implantation of allogeneic processed thymus tissue-agdc (RETHYMIC)] | Policies naming 60699 |
| 61736 | On the list | Laser interstitial thermal therapy (LITT) of lesion, intracranial, including burr hole(s), with magnetic resonance imaging guidance, when performed; single trajectory for 1 simple lesion | Policies naming 61736 |
| 61737 | On the list | Laser interstitial thermal therapy (LITT) of lesion, intracranial, including burr hole(s), with magnetic resonance imaging guidance, when performed; multiple trajectories for multiple or complex lesions | Policies naming 61737 |
All Anthem Blue Cross Blue Shield of California policies · Anthem Blue Cross Blue Shield of California prior authorization CPT list