Magnetic Resonance Guided Focused Ultrasound

Policy Number: MP 5.053

Effective Date: 1/1/2026

Política

Magnetic resonance-guided high-intensity ultrasound ablation may be considered medically necessary for pain palliation in adults with metastatic bone cancer who have failed or are not candidates for radiotherapy.

Magnetic resonance-guided high-intensity ultrasound ablation is considered investigational in all other situations, including but not limited to:

• Treatment of uterine fibroids;
• Treatment of other tumors (e.g. brain cancer, prostate cancer, breast cancer, desmoid);
• Treatment of medication-refractory tremor dominant Parkinson disease.

There is insufficient evidence to support a general conclusion concerning the health outcomes or benefits associated with this procedure.

Variaciones del producto

This policy is only applicable to certain programs and products administered by Capital Blue Cross and subject to benefit variations. Consulte la información adicional a continuación.

FEP PPO - Consulte el Manual de Políticas Médicas de FEP.

Descripción/Antecedentes

NA

Rational

Summary of Evidence

Uterine Fibroids

Uterine fibroids are one of the most common conditions affecting women in the reproductive years. Symptoms of uterine fibroids include menorrhagia, pelvic pressure, or pain.

Tratamiento

Several approaches currently available to treat symptomatic uterine fibroids include hysterectomy, abdominal myomectomy, laparoscopic and hysteroscopic myomectomy, hormone therapy, uterine artery embolization, and watchful waiting. Hysterectomy and various myomectomy procedures are considered the criterion standard treatment.

Metastatic Bone Disease

Metastatic bone disease is one of the most common causes of cancer pain.

Tremor-Dominant Parkinson Disease

The 3 cardinal features of Parkinson disease (PD) are tremor, bradykinesia, and rigidity. The tremor in PD is a resting tremor that occurs when the body part is not engaged in purposeful activities. Major subtypes of PD include tremor-dominant, akinetic-rigid, and postural instability and gait difficulty. The progression of PD is highly variable, and patients can change subtypes as the disease progresses.

Tratamiento

Dopaminergic therapy (i.e., levodopa or a dopamine agonist) is the first-line treatment for PD, which improves tremor. Amantadine and anticholinergics (e.g., trihexyphenidyl) can also be considered as initial treatment for tremor-dominant PD or as add-on therapy in patients who have persistent tremor despite dopaminergic therapy. For medication-refractory patients, surgery (deep brain stimulation or lesioning procedures) may be offered. Lesioning procedures include conventional unilateral thalamotomy and focused ultrasound thalamotomy. Deep brain stimulation is the most frequently performed surgical procedure for the treatment of PD.

Tratamiento

Existing treatments include conservative measures (e.g., massage, exercise) and pharmacologic agents (e.g., analgesics, bisphosphonates, and corticosteroids). For patients who do not respond to these treatments, standard care is external-beam radiotherapy. However, a substantial proportion of patients have residual pain after radiotherapy, and there is a need for alternative treatments for these patients.

Definiciones

NA

Exención de responsabilidad

Las políticas médicas de Capital Blue Cross se utilizan para determinar la cobertura de tecnologías, procedimientos, equipos y servicios médicos específicos. Estas políticas médicas no constituyen un consejo médico y están sujetas a cambios según lo exija la ley o la evidencia clínica aplicable de las pautas de tratamiento independientes. Los proveedores que brindan tratamiento son individualmente responsables de los consejos médicos y el tratamiento de los miembros. Estas pólizas no son una garantía de cobertura o pago. El pago de las reclamaciones está sujeto a la determinación del programa de beneficios del miembro y la elegibilidad en la fecha del servicio, y a la determinación de que los servicios son médicamente necesarios y apropiados. El procesamiento final de una reclamación se basa en los términos del contrato que se aplican al programa de beneficios de los miembros, incluidas las limitaciones y exclusiones de beneficios. Si un proveedor o miembro tiene alguna pregunta sobre esta política médica, debe comunicarse con Servicios para proveedores o Servicios para miembros de Capital Blue Cross.

Coding Information

Nota: Es posible que esta lista de códigos no sea exhaustiva y que los códigos estén sujetos a cambios en cualquier momento. La identificación de un código en esta sección no denota cobertura, ya que la cobertura está determinada por los términos de la información de beneficios del miembro. Además, no todos los servicios cubiertos son elegibles para un reembolso por separado. Los códigos deben estar en orden numérico.

Investigational, therefore not covered.

Covered when medically necessary.

Referencias

1. Eltoukhi HM, Modi MN, Weston M, et al. The health disparities of uterine fibroid tumors for African American women: a public health issue. Am J Obstet Gynecol. Mar 2014; 210(3): 194-9. PMID 23942040
2. Barnard EP, AbdElmagied AM, Vaughan LE, et al. Periprocedural outcomes comparing fibroid embolization and focused ultrasound: a randomized controlled trial and comprehensive cohort analysis. Am J Obstet Gynecol. May 2017; 216(5): 500.e1-500.e11. PMID 28063909
3. Laughlin-Tommaso S, Barnard EP, AbdElmagied AM, et al. FIRSTT study: randomized controlled trial of uterine artery embolization vs focused ultrasound surgery. Am J Obstet Gynecol. Feb 2019; 220(2): 174.e1-174.e13. PMID 30696556
4. Jacoby VL, Kohi MP, Poder L, et al. PROMISe trial: a pilot, randomized, placebo-controlled trial of magnetic resonance guided focused ultrasound for uterine fibroids. Fertil Steril. Mar 2016; 105(3): 773-780. PMID 26658133
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9. Otonkoski S, Sainio T, Mattila S, et al. Magnetic resonance guided high intensity focused ultrasound for uterine fibroids and adenomyosis has no effect on ovarian reserve. Int J Hyperthermia. 2023; 40(1): 2154575. PMID 36535925
10. Rabinovici J, David M, Fukunishi H, et al. Pregnancy outcome after magnetic resonance-guided focused ultrasound surgery (MRgFUS) for conservative treatment of uterine fibroids. Fertil Steril. Jan 2010; 93(1): 199-209. PMID 19013566
11. Baal JD, Chen WC, Baal U, et al. Efficacy and safety of magnetic resonance-guided focused ultrasound for the treatment of painful bone metastases: a systematic review and meta-analysis. Skeletal Radiol. Dec 2021; 50(12): 2459-2469. PMID 34018007
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19. Merckel LG, Knuttel FM, Deckers R, et al. First clinical experience with a dedicated MRI-guided high-intensity focused ultrasound system for breast cancer ablation. Eur Radiol. Nov 2016; 26(11): 4037-4046. PMID 26852219
20. McDannold N, Clement GT, Black P, et al. Transcranial magnetic resonance imaging- guided focused ultrasound surgery of brain tumors: initial findings in 3 patients. Neurosurgery. Feb 2010; 66(2): 323-32; discussion 332. PMID 20087132
21. Arrigoni F, Spiliopoulos S, de Cataldo C, et al. A Bicentric Propensity Score Matched Study Comparing Percutaneous Computed Tomography-Guided Radiofrequency Ablation to Magnetic Resonance-Guided Focused Ultrasound for the Treatment of Osteoid Osteoma. J Vasc Interv Radiol. Jul 2021; 32(7): 1044-1051. PMID 33775816
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25. Avedian RS, Bitton R, Gold G, et al. Is MR-guided High-intensity Focused Ultrasound a Feasible Treatment Modality for Desmoid Tumors?. Clin Orthop Relat Res. Mar 2016; 474(3): 697-704. PMID 26040967
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Historial de políticas

• MA 5.053
• New policy.