Magnetic Resonance Guided Focused Ultrasound

Policy Number: MP 5.053

Effective Date: 1/1/2026

Policy

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.

Product Variations

This policy is only applicable to certain programs and products administered by Capital Blue Cross and subject to benefit variations. Please see additional information below.

FEP PPO – Refer to FEP Medical Policy Manual.

Description/Background

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.

Treatment

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.

Treatment

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.

Treatment

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.

Definitions

NA

Disclaimer

Capital Blue Cross’ medical policies are used to determine coverage for specific medical technologies, procedures, equipment, and services. These medical policies do not constitute medical advice and are subject to change as required by law or applicable clinical evidence from independent treatment guidelines. Treating providers are solely responsible for medical advice and treatment of members. These polices are not a guarantee of coverage or payment. Payment of claims is subject to a determination regarding the member’s benefit program and eligibility on the date of service, and a determination that the services are medically necessary and appropriate. Final processing of a claim is based upon the terms of contract that applies to the members’ benefit program, including benefit limitations and exclusions. If a provider or a member has a question concerning this medical policy, please contact Capital Blue Cross’ Provider Services or Member Services.

Coding Information

Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement. The codes need to be in numerical order.

Investigational, therefore not covered.

Covered when medically necessary.

References

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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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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
12. Hurwitz MD, Ghanouni P, Kanaev SV, et al. Magnetic resonance-guided focused ultrasound for patients with painful bone metastases: phase III trial results. J Natl Cancer Inst. Apr 23 2014; 106(5). PMID 24760791
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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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23. Napoli A, Anzidei M, De Nunzio C, et al. Real-time magnetic resonance-guided high-intensity focused ultrasound focal therapy for localised prostate cancer: preliminary experience. Eur Urol. Feb 2013; 63(2): 395-8. PMID 23159454
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26. Bucknor MD, Rieke V. MRgFUS for desmoid tumors within the thigh: early clinical experiences. J Ther Ultrasound. 2017; 5: 4. PMID 28174660
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33. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology: Prostate Cancer. Version 1.2024
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Policy History

• MA 5.053
• New policy.