Magnetic Resonance Imaging (MRI)-Guided Focused Ultrasound Surgery (MRgFUS)

Policy ID: S-186-018

Section: Surgery

Effective Date: July 01, 2019

Revised Date: December 12, 2024

Revision Effective Date: January 01, 2025

Last Reviewed: January 14, 2025

Applies To: Commercial and Medicaid Expansion

Description

Magnetic Resonance Imaging (MRI)-Guided Focused Ultrasound Surgery (MRgFUS) is a non-invasive treatment that combines two (2) technologies, focused ultrasound (US) and MRI. The treatment is also called HIFU, which stands for High Intensity Focused Ultrasound.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Magnetic resonance imaging (MRI) - guided focused ultrasound surgery (MRgFUS) may be considered medically necessary for:

Pain palliation in adult individuals with metastatic bone cancer who failed or are not candidates for radiotherapy; or
Treatment of essential tremors.

MRgFUSnot meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Code

61715

MRgFUS is considered experimental/investigational for ALL other indications, including but not limited to:

Uterine fibroids
Breast tumors
Brain tumors
Prostate tumors
Chronic neuropathic pain

Procedure Codes

0071T

0072T

0947T

Diagnosis Codes

C79.51

G25.0

G25.89

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-19-2021 Coding Update -

Added diagnosis codes G25.0; and G25.89.

Internal Medical Policy Committee 1-20-2022 Coding Update- Effective January 01, 2022

Added procedure codes: 61736; and 61737; and
Removedprocedure code: 0398T

Internal Medical Policy Committee 1-26-2023 - Revision - Effective March 06, 2023

Updated with clarifying language; and
Removed procedure codes 61736; and 61737

Internal Medical Policy Committee 1-16-2024 Annual review - no changes in criteria

Internal Medical Policy Committee 9-17-2024 Annual review-no changes in criteria

Added Policy Application

Internal Medical Policy Committee 1-14-2025 Coding update - Effective January 01, 2025

Added procedure codes 0947T; 61715; and
Removed procedure code C9734

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: S-186-017

Section: Surgery

Effective Date: July 01, 2019

Revised Date: January 09, 2023

Revision Effective Date: November 04, 2024

Last Reviewed: September 17, 2024

Archived Date: December 31, 2024