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Horizon BCBSNJ
Uniform Medical Policy ManualSection:Surgery
Policy Number:143
Effective Date: 07/10/2015
Original Policy Date:01/27/2015
Last Review Date:07/10/2018
Date Published to Web: 06/08/2015
Subject:
Ablation Procedures for Peripheral Neuromas

Description:
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IMPORTANT NOTE:

The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.

Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.

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Morton neuroma is a common and painful compression neuropathy of the dorsal foot. Morton neuroma has been treated with conservative measures (pads, orthotics, drugs) or surgery. Minimally invasive procedures, including radiofrequency ablation (RFA) and cryoablation, have been investigated as alternatives to open surgery. These ablation methods have also been used to treat other peripheral neuromas.

Populations
Interventions
Comparators
Outcomes
Individuals:
With Morton neuroma
Interventions of interest are:
Radiofrequency ablation
Comparators of interest are:
Conservative therapy
Surgical therapy
Relevant outcomes include:
Symptoms
Functional outcomes
Treatment-related morbidity
Individuals:
With Morton neuroma
Interventions of interest are:
Cryoablation
Comparators of interest are:
Conservative therapy
Surgical therapy
Relevant outcomes include:
Symptoms
Functional outcomes
Treatment-related morbidity
Individuals:
With peripheral neuroma(s) other than Morton neuroma
Interventions of interest are:
Ablation
Comparators of interest are:
Conservative therapy
Surgical therapy
Relevant outcomes include:
Symptoms
Functional outcomes
Treatment-related morbidity

Background

Neuroma
A neuroma is a pathology of a peripheral nerve that develops as part of a normal reparative process. Neuromas may develop after nerve injury or result from chronic irritation, pressure, stretch, poor repair of nerve lesions or previous neuromas, laceration, crush injury, or blunt trauma.1 Neuromas typically appear 6 to 10 weeks after trauma, with most presenting within 1 to 12 months after injury or surgery. They may gradually enlarge over 2 to 3 years and may or may not be painful. Pain from a neuroma may be secondary to traction on the nerve by scar tissue, compression of the sensitive nerve endings by adjacent soft tissues, ischemia of the nervous tissue, or ectopic foci of ion channels that elicit neuropathic pain. Patients may describe the pain as low-intensity dull pain or intense paroxysmal burning pain, often triggered by external stimuli such as touch or temperature. Neuroma formation has been implicated as a contributor of neuropathic pain in residual limb pain, postthoracotomy, postmastectomy, and postherniorrhaphy pain syndromes. They may coexist with phantom pain or can predispose to it.

Morton Neuroma
Morton intermetatarsal neuroma is a common and painful compression neuropathy of the common digital nerve of the foot that may also be referred to as interdigital neuroma, interdigital neuritis, and interdigital or Morton metatarsalgia.1-3 Morton neuroma is usually associated with a throbbing, burning, or shooting pain localized to the plantar aspect of the foot. It is typically located between the third and fourth metatarsal heads, although it may appear in other proximal locations.1,2 It is histologically characterized by perineural fibrosis, endoneurial edema, axonal degeneration, and local vascular proliferation. Thus, some investigators do not consider Morton neuroma to be a true neuroma; instead, they consider it to be an entrapment neuropathy occurring secondary to compression of the common digital nerve under the overlying transverse metatarsal ligament. Morton neuroma appears 10-fold more often in women than in men, with an average age at presentation of around 50 years.4

Diagnosis
Although a host of imaging methods are used to diagnosis Morton neuroma, including plain radiographs, magnetic resonance imaging, and ultrasonography, objective findings are unique to this condition and are primarily used to establish a clinical diagnosis.1 Thus, a patient’s toes often show splaying or divergence. Patients may describe the feeling of a “lump” on the foot bottom or a feeling of walking on a rolled-up or wrinkled sock. Clinical examination with medial and lateral compression may reproduce the painful symptoms with a palpable “click” on interspace compression (Mulder sign).5

Treatment
Management of patients diagnosed with Morton neuroma typically starts with conservative approaches, such as the use of metatarsal pads in shoes and orthotic devices that alter supination and pronation of the affected foot.3 These approaches try to reduce pressure and irritation of the affected nerve. They may provide relief, but do not alter the underlying pathology. There is scant evidence to support the effectiveness or comparative effectiveness of these practices.2,6,7 In a case series, Bennett et al (1995) evaluated a 3-stage protocol of “stepped care” through which private practice patients (N=115) advanced from stage I (education plus footwear modifications, and a metatarsal pad) to stage II (steroid injections with local anesthetic or local anesthetic alone), and into stage III (surgical resection) if stages I and II were not relieved within 3 months.8 Overall, 97 (85%) of 115 patients believed that pain had been reduced with the treatment program. However, 24 (21%) patients eventually required surgical excision of the nerve, and 23 (96%) of them had satisfactory results.

Ablation Techniques
Several minimally invasive procedures to treat refractory Morton neuroma are aimed at in situ destruction of the pathology: radiofrequency ablation (RFA) and cryoablation (also known as cryoneurolysis, cryolysis, cryoanalgesia).2 RFA uses heat generated by an electrode that conducts electromagnetic energy into a tissue or lesion to denature proteins and destroy cells. RFA is used to ablate a wide range of tissues or lesions, including osteoid osteoma; cardiovascular system pathologies; cervical pain syndromes; liver, lung, and other cancers; and varicosities.9-20 Cryoablation uses coolant to chill a cryoprobe to temperatures below -75C, which when inserted into a lesion, freezes and kills the tissue. It has been used to treat Morton neuroma, other chronic nerve pain syndromes, and conditions for which RFA has been used.21-28

This review primarily focuses on evidence for the use of RFA and cryoablation on painful neuromas, with emphasis on Morton neuroma and the comparative effectiveness of these less invasive therapies with open surgical resection of the nerve pathology.

Regulatory Status
Although RFA probes and generators and cryoablation equipment have been cleared for marketing by the U.S. Food and Drug Administration through the 510(k) process, none appear to be specifically indicated for the treatment of Morton neuroma or any other specific peripheral neuroma.

Related Policies

  • None

Policy:
(NOTE: For Medicare Advantage, please refer to the Medicare Coverage Section below for coverage guidance.)

Minimally invasive ablation procedures, radiofrequency ablation, and cryoablation, are considered investigational for the treatment of peripheral neuromas.


Medicare Coverage:
There is no National Coverage Determination (NCD or Local Coverage Determination (LCD) for jurisdiction JL for this service. Therefore, Medicare Advantage will follow the
Horizon BCBSNJ Medical Policy.


[RATIONALE: This policy was created in 2015 and has been updated regularly with searches of the MEDLINE database. The most recent literature update was performed through April 9, 2018.

Evidence reviews assess the clinical evidence to determine whether the use of a technology improves the net health outcome. Broadly defined, health outcomes are length of life, quality of life, and ability to functionincluding benefits and harms. Every clinical condition has specific outcomes that are important to patients and to managing the course of that condition. Validated outcome measures are necessary to ascertain whether a condition improves or worsens; and whether the magnitude of that change is clinically significant. The net health outcome is a balance of benefits and harms.

To assess whether the evidence is sufficient to draw conclusions about the net health outcome of technology, 2 domains are examined: the relevance and the quality and credibility. To be relevant, studies must represent one or more intended clinical use of the technology in the intended population and compare an effective and appropriate alternative at a comparable intensity. For some conditions, the alternative will be supportive care or surveillance. The quality and credibility of the evidence depend on study design and conduct, minimizing bias and confounding that can generate incorrect findings. The randomized controlled trial is preferred to assess efficacy; however, in some circumstances, nonrandomized studies may be adequate. Randomized controlled trials are rarely large enough or long enough to capture less common adverse events and long-term effects. Other types of studies can be used for these purposes and to assess generalizability to broader clinical populations and settings of clinical practice.

Clinical Context and Therapy Purpose
The purpose of peripheral nerve ablation (ie, radiofrequency ablation [RFA] or cryoablation) in patients who have peripheral neuromas is to provide a treatment option that is an alternative to or an improvement on existing therapies.

The question addressed in this policy is: Do minimally invasive ablation procedures improve health outcomes in patients with peripheral neuromas?

The following PICOTS were used to select literature to inform this review.

Patients
The relevant population of interest is patients with peripheral neuromas, with emphasis on Morton neuroma.

Interventions
The therapies being considered are RFA and cryoablation for painful neuromas.

Comparators
The following practice is currently being used to make decisions about the treatment of peripheral neuromas: open surgical resection of the nerve pathology.

Outcomes
The general outcomes of interest are pain, typically measured with a visual analog score (VAS), ability to walk, and adverse events related to ablation procedures.

Timing
The timing ranges from hours for the immediate effect of treatment, to months to assess recurrence of treatment.

Setting
The setting may include pain clinics or other specialist care centers that have the equipment to perform RFA or cryoablation.

Radiofrequency Ablation for Morton Neuroma
Three case series were identified reporting outcomes with RFA for treating Morton neuroma.

Genon et al (2010) reported on a retrospective review of a single center’s experience with RFA to treat Morton neuroma according to a clinical algorithm that proceeds from nonoperative interventions to RFA and to open neurectomy if initial approaches failed.29 Thirty-seven patients who had failed conservative management (not described) and had symptoms for at least 12 months in duration were treated with RFA using a NeuroTherm NT1000 (NeuroTherm) radiofrequency generator. At an average follow-up of 11 months (range, 3-21 months), among the 37 patients (38 neuromas) treated, 7 (19%) reported complete relief of symptoms, 21 (58%) reported partial relief, and 10 (27%) reported no relief. Among those with no relief, 8 (22%) of patients had an open surgical revision, with 6 of 8 reporting complete relief, 3 reporting partial relief, and 1 was unchanged. No complications due to RFA were reported.

Moore et al (2012) reported on a second retrospective series of RFA management of Morton neuroma.30 This series included 29 patients (22 women; age range, 23-73 years) who had not responded to conservative management (primarily steroid and alcohol injections) over 1 to 2 months. Patients were treated with RFA (Smith & Nephew) under monitored anesthesia using an electrode inserted dorsally with fluoroscopic guidance. Among the 29 patients, 24 (83%) expressed complete relief of symptoms 1 month after RFA; none reported more pain. The remaining 5 (17%) had minimal to no relief. Of them, one had an open revision, and the others had no additional treatment or were lost to follow-up. One patient reported recurrence 9 months following RFA, and another had superficial cellulitis that responded to antibiotic therapy. All patients returned to normal shoe gear and activities within 2 days of RFA.

Chuter et al (2013) reported on a third retrospective series of RFA to treat Morton neuroma.31 This series included 25 patients (21 women) with a mean age of 55 years (range, 33-73 years) who had mean symptom duration of 3.8 years (range, 6 months to 15 years). All failed conservative management. Before RFA, patients had an average pain score of 6.0 (range, 3.0-9.0) on a 10-point VAS. Four weeks after RFA, the average VAS pain score was 1.7 (range, 0-8.0; p<0.001), an average symptom improvement of 76%. The only complication reported involved a patient who experienced irritation of the posterior tibial nerve following the procedure. Three (10%) patients proceeded to open surgical excision within 6 months of RFA due to incomplete pain relief or recurrence.

Section Summary: Radiofrequency Ablation for Morton Neuroma
Three case series have reported outcomes of RFA to treat Morton neuroma. The body of evidence is highly heterogeneous regarding RFA protocols used, prior conservative management, patient characteristics, follow-up durations, outcome measures, and the reporting of outcomes (eg, using denominators of “feet,” “neuromas,” or “patients,” which required conversion to “patients”). Although favorable outcomes were achieved in substantial proportions in each study, the outcome measures were unclear as to their clinical meaning, except the VAS used in the Chuter report. Furthermore, in all 3 series, a variable proportion of patients required further surgical excision, making the value of prior RFA uncertain.

Cryoablation for Morton Neuroma
Two retrospective case series on the use of cryoablation to treat peripheral nerve pain have been identified.

One case series by Friedman et al (2012) reported on a series of patients who had undergone sonographically guided cryoneurolysis.32 Among a cohort of 20 patients, 5 had Morton neuroma (all women; mean age, 55 years). Cryotherapy was administered with a Frigitronics CE 2000 (Cooper Surgical) device using nitrous oxide coolant. A cryoprobe was inserted into the Morton neuroma, and the probe temperature was decreased to -75C and left in place until a continuous series of ice balls was created (one or two 3-minute cycles of cooling). Patients were scheduled for follow-up at 4 to 6 weeks. However, actual follow-up varied due to patient discretion. Among the 5 Morton neuroma patients, 3 had “marked relief,” 1 had “moderate relief,” and 1 had no relief, at a mean follow-up of 14 weeks (range, 6 weeks to 14 months). Complications of cryoablation were not reported.

The second case series, by Cazzato et al (2016), retrospectively described 20 patients (24 lesions) with Morton neuroma who underwent magnetic resonanceguided cryoablation.33 All patients were previously treated with ultrasound-guided corticosteroid injections and had not reported relief. While positioned in the magnetic resonance unit, a cryoprobe (Ice-Seed; Galil Medical) was inserted into the center of the lesion. A single freezing cycle of 150 seconds was performed. Mean procedural time was 41 minutes (range, 35-60 minutes). Patients were followed with a telephone survey. The number of months between procedure and last follow-up ranged from 1 to 50 months. Results were reported by lesion, with data available for 18 of the 24 lesions treated. Patients with 14 (78%) of the 18 lesions were “completely satisfied,” 17% were “satisfied with minor reservations,” and 6% were “satisfied with major reservations.” Mean local pain score was 3.0 on a 0-to-10 VAS. Post-VAS scores were not available.

Section Summary: Cryoablation for Morton Neuroma
Two retrospective case series have investigated cryoablation to treat Morton neuroma. The body of evidence is heterogeneous regarding cryoablation protocols used, prior conservative management, and length of follow-up. Although large proportions of patients reported satisfaction with the procedure in both studies, daily functioning did not clearly improve after the procedure. The weaknesses in the body of evidence preclude conclusions on the efficacy of cryoablation for Morton neuroma.

Other Painful Neuromas
The literature review for this update did not identify any controlled studies on the use of ablative techniques to treat painful peripheral neuromas other than Morton neuroma. Two recent review articles reported little evidence for any other sites.1,32

Section Summary: Other Painful Neuromas
The current literature base on the use of ablative techniques for peripheral neuromas other than Morton neuroma provides insufficient data on which to form conclusions about treatment efficacy.

Summary of Evidence
For individuals who have Morton neuroma who receive RFA, the evidence includes case series. Relevant outcomes are symptoms, functional outcomes, and treatment-related morbidity. Three case series identified reported outcomes for RFA to treat Morton neuroma. The body of evidence is highly heterogeneous regarding RFA protocols, prior conservative management, patient characteristics, follow-up durations, outcome measures, and reporting of outcomes. Variable proportions of patients require surgery after RFA, making the benefit of RFA for avoiding more invasive treatment uncertain. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have Morton neuroma who receive cryoablation, the evidence includes case series. Relevant outcomes are symptoms, functional outcomes, and treatment-related morbidity. Only 2 retrospective case series on the use of cryoablation to treat peripheral nerve pain were identified in a literature review. The case series were heterogeneous regarding cryoablation protocols and length of follow-up. Outcome measures did not provide information on functional end points. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have peripheral neuroma(s) other than Morton neuroma who receive ablation, the evidence is very limited: no published literature was identified. Relevant outcomes are symptoms, functional outcomes, and treatment-related morbidity. The evidence is insufficient to determine the effects of the technology on health outcomes.

Supplemental Information

Practice Guidelines and Position Statements
The Association of Extremity Nerve Surgeons (2014) published clinical practice guidelines relevant to this policy.34 The guidelines stated that “We do not recommend ablation in the primary treatment of Intermetatarsal Entrapment (Morton’s Neuroma).” The guidelines warned that cryoablation should be used with extreme caution, and, if used, should be performed in an open technique, not percutaneously. The guidelines also warned that radiofrequency ablation might cause thermal necrosis of adjacent tissues.

U.S. Preventive Services Task Force Recommendations
Not applicable.

Ongoing and Unpublished Clinical Trials
Some currently unpublished trials that might influence this review are listed in Table 1.

Table 1. Summary of Key Trials
NCT No.
Trial Name
Planned Enrollment
Completion Date
Ongoing
NCT02838758A 3-Arm Randomized Controlled Study Comparing Ultrasound-Guided Cryoablation, Ultrasound-Guided Perineural Lidocaine, and Ultrasound-Guided Perineural Saline to Treat Intrametatarsal Neuroma]
66
Dec 2020


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Horizon BCBSNJ Medical Policy Development Process:

This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.

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Index:
Ablation Procedures for Peripheral Neuromas
Cryoablation of Peripheral Neuroma
Radiofrequency Ablation of Peripheral Neuroma
Cryoneurolysis of Peripheral Neuroma
Cryolysis of Peripheral Neuroma
Cryoanalgesia of Peripheral Neuroma
Neuroma, Ablation Procedures for
Morton's Neuroma, Ablation Procedures for

References:
1. Rajput K, Reddy S, Shankar H. Painful neuromas. Clin J Pain. Sep 2012;28(7):639-645. PMID 22699131

2. Jain S, Mannan K. The diagnosis and management of Morton's neuroma: a literature review. Foot Ankle Spec. Aug 2013;6(4):307-317. PMID 23811947

3. Clinical Practice Guideline Forefoot Disorders Panel, Thomas JL, Blitch ELt, et al. Diagnosis and treatment of forefoot disorders. Section 3. Morton's intermetatarsal neuroma. J Foot Ankle Surg. Mar-Apr 2009;48(2):251-256. PMID 19232980

4. Wu KK. Morton's interdigital neuroma: a clinical review of its etiology, treatment, and results. J Foot Ankle Surg. Mar-Apr 1996;35(2):112-119; discussion 187-118. PMID 8722878

5. Mulder JD. The causative mechanism in Morton's metatarsalgia. J Bone Joint Surg Br. Feb 1951;33-B(1):94-95. PMID 14814167

6. Adams WR, 2nd. Morton's neuroma. Clin Podiatr Med Surg. Oct 2010;27(4):535-545. PMID 20934103

7. Thomson CE, Gibson JN, Martin D. Interventions for the treatment of Morton's neuroma. Cochrane Database Syst Rev. Jul 2004(3):CD003118. PMID 15266472

8. Bennett GL, Graham CE, Mauldin DM. Morton's interdigital neuroma: a comprehensive treatment protocol. Foot Ankle Int. Dec 1995;16(12):760-763. PMID 8749346

9. Dierselhuis EF, van den Eerden PJ, Hoekstra HJ, et al. Radiofrequency ablation in the treatment of cartilaginous lesions in the long bones: results of a pilot study. Bone Joint J. Nov 2014;96-B(11):1540-1545. PMID 25371471

10. Boersma D, van Eekeren RR, Kelder HJ, et al. Mechanochemical endovenous ablation versus radiofrequency ablation in the treatment of primary small saphenous vein insufficiency (MESSI trial): study protocol for a randomized controlled trial. Trials. Oct 29 2014;15(1):421. PMID 25354769

11. Di Costanzo GG, Tortora R, D'Adamo G, et al. Radiofrequency ablation versus laser ablation for the treatment of small hepatocellular carcinoma in cirrhosis: a randomized trial. J Gastroenterol Hepatol. Mar 2015;30(3):559-565. PMID 25251043

12. Anchala PR, Irving WD, Hillen TJ, et al. Treatment of metastatic spinal lesions with a navigational bipolar radiofrequency ablation device: a multicenter retrospective study. Pain Physician. Jul-Aug 2014;17(4):317-327. PMID 25054391

13. Hillen TJ, Anchala P, Friedman MV, et al. Treatment of metastatic posterior vertebral body osseous tumors by using a targeted bipolar radiofrequency ablation device: technical note. Radiology. Oct 2014;273(1):261-267. PMID 24927327

14. Wang X, Wang X, Song Y, et al. Efficiency of radiofrequency ablation for surgical treatment of chronic atrial fibrillation in rheumatic valvular disease. Int J Cardiol. Jul 01 2014;174(3):497-502. PMID 24820759

15. Huang WZ, Wu YM, Ye HY, et al. Comparison of the outcomes of monopolar and bipolar radiofrequency ablation in surgical treatment of atrial fibrillation. Chin Med Sci J. Mar 2014;29(1):28-32. PMID 24698675

16. Avery J, Kumar K, Thakur V, et al. Radiofrequency ablation as first-line treatment of varicose veins. Am Surg. Mar 2014;80(3):231-235. PMID 24666862

17. Hiraki T, Gobara H, Iguchi T, et al. Radiofrequency ablation as treatment for pulmonary metastasis of colorectal cancer. World J Gastroenterol. Jan 28 2014;20(4):988-996. PMID 24574771

18. Morillo CA, Verma A, Connolly SJ, et al. Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of paroxysmal atrial fibrillation (RAAFT-2): a randomized trial. JAMA. Feb 19 2014;311(7):692-700. PMID 24549549

19. Fuller CW, Nguyen SA, Lohia S, et al. Radiofrequency ablation for treatment of benign thyroid nodules: systematic review. Laryngoscope. Jan 2014;124(1):346-353. PMID 24122763

20. Huang XM, Hu JQ, Li ZF, et al. Symptomatic sinus tachycardia with perpetuating slow pathway: successful treatment with radiofrequency ablation. Pacing Clin Electrophysiol. Oct 2014;37(10):e1-4. PMID 21077914

21. Prologo JD, Passalacqua M, Patel I, et al. Image-guided cryoablation for the treatment of painful musculoskeletal metastatic disease: a single-center experience. Skeletal Radiol. Nov 2014;43(11):1551-1559. PMID 24972918

22. Kim EH, Tanagho YS, Saad NE, et al. Comparison of laparoscopic and percutaneous cryoablation for treatment of renal masses. Urology. May 2014;83(5):1081-1087. PMID 24560975

23. Durand M, Barret E, Galiano M, et al. Focal cryoablation: a treatment option for unilateral low-risk prostate cancer. BJU Int. Jan 2014;113(1):56-64. PMID 24053685

24. Duarte R, Pereira T, Pinto P, et al. [Percutaneous image-guided cryoablation for localized bone plasmacytoma treatment]. Radiologia. Sep-Oct 2014;56(5):e1-4. PMID 22621822

25. Rodriguez-Entem FJ, Exposito V, Gonzalez-Enriquez S, et al. Cryoablation versus radiofrequency ablation for the treatment of atrioventricular nodal reentrant tachycardia: results of a prospective randomized study. J Interv Card Electrophysiol. Jan 2013;36(1):41-45; discussion 45. PMID 23080326

26. Yamauchi Y, Izumi Y, Hashimoto K, et al. Percutaneous cryoablation for the treatment of medically inoperable stage I non-small cell lung cancer. PLoS One. Mar 2012;7(3):e33223. PMID 22413004

27. Collins KK, Schaffer MS. Use of cryoablation for treatment of tachyarrhythmias in 2010: survey of current practices of pediatric electrophysiologists. Pacing Clin Electrophysiol. Mar 2011;34(3):304-308. PMID 21077912

28. Kaufman CS, Bachman B, Littrup PJ, et al. Cryoablation treatment of benign breast lesions with 12-month follow-up. Am J Surg. Oct 2004;188(4):340-348. PMID 15474424

29. Genon MP, Chin TY, Bedi HS, et al. Radio-frequency ablation for the treatment of Morton's neuroma. ANZ J Surg. Sep 2010;80(9):583-585. PMID 20857612

30. Moore JL, Rosen R, Cohen J, et al. Radiofrequency thermoneurolysis for the treatment of Morton's neuroma. J Foot Ankle Surg. Jan-Feb 2012;51(1):20-22. PMID 22055491

31. Chuter GS, Chua YP, Connell DA, et al. Ultrasound-guided radiofrequency ablation in the management of interdigital (Morton's) neuroma. Skeletal Radiol. Jan 2013;42(1):107-111. PMID 23073898

32. Friedman T, Richman D, Adler R. Sonographically guided cryoneurolysis: preliminary experience and clinical outcomes. J Ultrasound Med. Dec 2012;31(12):2025-2034. PMID 23197557

33. Cazzato RL, Garnon J, Ramamurthy N, et al. Percutaneous MR-guided cryoablation of Morton's neuroma: rationale and technical details after the first 20 patients. Cardiovasc Intervent Radiol. Oct 2016;39(10):1491-1498. PMID 27189181

34. Barrett SL, Nickerson DS, Elison P, et al. Clinical Practice Guidelines. Edition 1. Wimberley, TX: Association of Extremity Nerve Surgeons; 2014.

Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)

CPT*

    64632
    64640
HCPCS

* CPT only copyright 2018 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.

The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy

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