TN 61 (10-23)

DI 23022.205 Kidney Cancer - Inoperable or Unresectable




Kidney Carcinoma; Renal Cell Cancer; RCC; Renal Cell Carcinoma; Wilms Tumor; Renal Pelvis Carcinoma; Renal Adenocarcinoma; Clear Cell Sarcoma of the Kidney; Rhabdoid Tumor of the Kidney; Neuroepithelial Tumor of the Kidney; Diffuse Hyperplastic Perilobar Nephroblastomatosis; Transitional Cell Carcinoma; Urothelial Carcinoma; Hypernephroma


Kidney Cancer is cancer that forms in tissues of the kidneys (renal cells). Kidney Cancer develops most often in people over 40, but no one knows the exact causes of this disease. Smoking and misuse of certain pain medicines including over-the-counter pain medicines for a long time can affect the risk of developing renal cell cancer. Also, certain genetic conditions, such as von Hippel-Lindau disease or hereditary papillary renal cell carcinoma put a person at risk for this disease. These genetic variations account for a small number of cases, approximately 5%. Clear Cell Sarcoma of the Kidney is a rare type of kidney cancer, in which the inside of the cells look clear when viewed under a microscope. Clear Cell Sarcoma can spread from the kidney to other organs, most commonly the bone, but also the lungs, brain, and soft tissues of the body.


Diagnostic Testing: Diagnostic testing may include physical exam and history, blood chemistry studies, urinalysis, liver function tests, intravenous pyelogram (IVP), ultrasound exam, CT scan, MRI, and biopsy.

Physical findings: There may be no symptoms of Kidney Cancer in the early stages. Symptoms may appear as the tumor grows. Symptoms include:

  • Fever;

  • Blood in the urine;

  • A lump in the abdomen;

  • Pain in the side that does not go away;

  • Loss of appetite;

  • Weight loss; and

  • Anemia.

ICD-9: 189.0,189.1, 233.9

ICD-10: C7A.093


Generally, if the disease is limited and surgery removes the disease, 5-year survival is good. However, when the disease is inoperable, unresectable, or metastatic, prognosis is poor.


Standard treatment for Kidney Cancer includes surgery to remove all or part of the kidney, radiation therapy, chemotherapy, biologic therapy, and targeted therapy.

An individual can live with part of one working kidney, but if both kidneys are removed or not working, the person will need dialysis (a procedure to clean the blood using a machine outside of the body) or a kidney transplant (replacement with a healthy donated kidney). A kidney transplant may be done when the disease is in the kidney only and a donated kidney can be found.

Targeted therapy uses drugs or other substances that can find and attack specific cancer cells without harming normal cells. Antiangiogenic agents are a type of targeted therapy that may be used to treat advanced Kidney Cancer. They keep blood vessels from forming in a tumor, causing the tumor to starve and stop growing or to shrink.


Suggested MER for Evaluation:

  • Clinical note from a surgeon that the cancer is inoperable; and

  • Surgical pathology report that the cancer was not completely removed and that the surgical margins were positive for malignancy.

“Inoperable” refers to a physician's opinion that surgery would not be beneficial based on a review of imaging studies, laboratory results, and physical examination findings.

“Unresectable” cancer is established when the operative report indicates that the cancer is not completely removed or the pathology report notes that the surgical specimen has positive margins.

Suggested Listings for Evaluation:





13.21 A

Biopsy proof of Kidney Cancer and clinical note stating tumor is inoperable or pathology report or operative note indicating tumor was unresectable or had positive surgical margin.




* Adjudicators may, at their discretion, use the Medical Evidence of Record or the listings suggested to evaluate the claim. However, the decision to allow or deny the claim rests with the adjudicator.


To Link to this section - Use this URL:
DI 23022.205 - Kidney Cancer - Inoperable or Unresectable - 10/05/2023
Batch run: 10/05/2023