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Contractor Name

CareFirst of Maryland Inc., Medicare Part A

Contractor Number

00190

Contractor Type

Fiscal Intermediary

LCD Database ID Number

L747

LCD Title

Cryosurgery in the Treatment of Liver Tumors

Contractor's Determination Number

00-05-R2

AMA/CPT and ADA/CDT Copyright Statement

CPT codes, descriptions, and other data only are copyright 1999 American Medical Association (or such publication of CPT). All rights reserved. Applicable FARS/DFARS clauses apply. CDT-4 codes and descriptions are ©2004 American Dental Association.  All rights reserved.

CMS National Coverage Policy

  • Establishment of national policy supersedes all previous contractor policy statements, including Local Medical Policy coverage guidelines
  • Title XVIII of the Social Security Act, section 1862 (a) (7). This section excludes routine physical examinations.
  • Title XVIII of the Social Security Act, section 1862 (a) (1) (A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
  • Title XVIII of the Social Security Act, section 1862 (a) (1) (D). This section excludes services determined to be investigational or experimental.

Primary Geographic Jurisdiction

Maryland

Washington, DC

Secondary Geographic Jurisdiction

Alabama, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Illinois, Iowa, Kansas, Kentucky, Louisiana, Maine, Massachusetts, Michigan, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, Washington state, and Wyoming

Oversight Region

Region III

CMS Consortium

Northeast

Original Determination Effective Date

06/26/2000

Revision Effective Date

09/01/2004

Indications and Limitations of Coverage and/or Medical Necessity

Description

Cryosurgery is a means for surgical destruction of diseased tissue. It has been used for many years in many medical fields including dermatology, neurosurgery, proctology, gynecology, and otolaryngology. In the last 10-15 years, much work has been done in applying this modality to the treatment of liver tumors, both primary and metastatic The biggest breakthrough in the field of cryosurgery for liver tumors has been the application of intraoperative ultrasound both to detect small lesions and to monitor the cryosurgical destruction process in order to assure complete ablation of the desired lesion, with a margin of normal tissue. In the treatment of liver tumors, cryosurgical destruction is often used in addition to surgical resection.

Indications and Limitations

Cryosurgery in the treatment of certain selected primary and secondary liver tumors is considered safe and effective in the following clinical scenarios:

  • Primary hepatocellular carcinoma when conventional surgical resection is felt to be contraindicated or when cryosurgical ablation is used as an adjunct to surgical resection,
  • Carcinomas metastatic to the liver from colon, small intestine, ovarian, or neuroendocrine primaries,
  • Carcinomas metastatic to the liver must meet all of the following qualifying conditions:
    • the primary cancer site must be effectively controlled,
    • the metastatic lesions must be limited to the liver and not present in other organs,
    • the open laparotomy approach must be used,
    • the patient must have no more than three liver metastases (except as described in the "Other Comments" section of this policy, and;
    • no lesion should be larger than 7 cm. in size.

Note: Metastases to the liver from primary carcinomas of the breast, lung, stomach, pancreas, adenocarcinoma of unknown origin, and other such primaries that tend to be disseminated widely at the same time that liver metastases are present, are not appropriate for treatment by cryosurgical ablation.

  • The cryosurgical device used must be FDA approved for the indications used.

Coverage Topic

Outpatient Hospital Services

Bill Type Codes

11X, 13X, 21X, 83X

Revenue Codes

360, 402

CPT/HCPCS Codes

The AMA and CMS require the use of short descriptors for policies published on the Web. Refer to the CPT book for the long description of the following codes:

47371

 

Laparo ablate liver cryosurg

47381

 

Open ablate liver tumor cryo

76986

 

Ultrasound guide intraoper

76490

 

Ultrasound guidance, tissue ablation

 

Does the “CPT 30% Coding Rule” Apply?

N/A

ICD-9 Codes that Support Medical Necessity

When procedure code 47381 with or without 76490 or 76986 are used to report "Cryosurgery in the Treatment of Liver Tumors" as described within this policy, the following diagnosis code(s) will be considered by Medicare to support medical necessity:

152.0

 

Malignant neoplasm of small intestine; duodenum

152.1

 

jejunum

152.2

 

ileum

152.8

 

Other specified sites of small intestine

152.9

 

Small intestine, unspecified

153.0

 

Malignant neoplasm of colon; hepatic flexure

153.1

 

transverse colon

153.2

 

descending colon

153.3

 

sigmoid colon

153.4

 

cecum

153.5

 

appendix

153.6

 

ascending colon

153.7

 

splenic flexure

153.8

 

other specified sites of large intestine

153.9

 

unspecified

154.0

 

Malignant neoplasm; rectosigmoid junction

154.1

 

rectum

154.2

 

anal canal

154.3

 

anus, unspecified

154.8

 

Other

155.0

 

Malignant neoplasm of liver, primary

183.00

 

Malignant neoplasm of ovary

197.7

 

Secondary malignant neoplasm of liver

 

Diagnoses that Support Medical Necessity

N/A

 

ICD-9 Codes that DO NOT Support Medical Necessity

Any diagnosis codes not listed in the "ICD-9 Codes that Support Medical Necessity" section of this policy

 

Diagnoses that DO NOT Support Medical Necessity

Conditions not listed in the "ICD-9 Codes that Support Medical Necessity" section of this policy.

Documentation Requirements

  • Documentation supporting the medical necessity should be legible, maintained in the patient's medical record, and available to Medicare upon request.
  • There must be a written report of the intraoperative echography in the patient's medical records. This requirement is considered to be met when the surgeon's operative note describes the use of intraoperative echography during the procedure.
  • In rare instances, such as multiple neuroendocrine liver metastases, more than three (3) liver metastases might be appropriately treated with cryosurgery or a combination of cryosurgery and surgical excision. When this occurs, the operative note should explain in detail the clinical situation necessitating treatment of more than three (3) metastases. This detailed operative note should be available to Medicare upon request.

Utilization Guidelines

N/A

 Sources of Information and Basis for Decision

  • TrailBlazer Carrier, LMRP
  • Carrier Medical Director, New Technology Workgroup
  • Wellmark, Part B Local Medical Policy

Advisory Committee Notes

This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).

Advisory Committee Meeting Date: N/A

Start Date of Comment Period

04/05/2000

End Date of Comment Period

05/26/2000

Start Date of Notice Period

05/26/2000

Revision History

Number

 

Date

 

Change

R-2

 

09/01/2004

 

Modified revenue codes, to include only 360 and 402 to make more

 

 

 

 

specific to the policy. Converted from LMRP to LCD.

00-05-R1

 

02/19/2003

 

Expanded coverage with addition of HCPCS 47371, 47381, and 76490.

 

 

 

 

HCPCS 47381 replaced 49200. CPT descriptors changed to short

 

 

 

 

descriptor, ICD-9 codes unranged.

 

THIS BULLETIN SHOULD BE SHARED WITH ALL HEALTH CARE PRACTITIONERS AND MANAGERIAL MEMBERS OF THE PROVIDER/SUPPLIER STAFF. BULLETINS ISSUED AFTER OCTOBER 1, 1999 ARE AVAILABLE FROM OUR WEBSITE AT www.marylandmedicare.com

Italicized and or quoted material is excerpted from the American Medical Association Current Procedural Terminology CPT codes, descriptions and other data only are copyrighted 1999 American Medical Association (or such other publication of CPT). All rights reserved. Applicable FARS/DFARS apply.