2004; 63(2):297-300. Available at: High Intensity Ultrasound System for Prostate Tissue Ablation (TULSA-PRO System). Prostate Cancer (V1.2023). Updated Discussion/General Information and Reference sections. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card. Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general adoption by plans or lines of business for consistent review of the medical necessity of services related to the clinical guideline when the plan performs utilization review for the subject. 2016; 19(3):311-316. Errico A. In addition to treatment, these individuals should undergo a sonographic fetal evaluation to evaluate for signs of fetal or placental syphilis. 2004; 58(4):382-390. Hematology/Oncology Subcommittee review. Focal therapy with high-intensity-focused ultrasound in the treatment of localized prostate cancer. Find a doctor near you. Two-year results of transurethral resection of the prostate versus four 'less invasive' treatment options. Updated Coding, Description, Discussion/General Information, and References. Providers are responsible for billing the appropriate CPT code, modifier, and diagnosis combinations. Single high intensity focused ultrasound session as a whole gland primary treatment for clinically localized prostate cancer: 10-year outcomes. Reaffirmed 2018. Available at: Dahm P, Brasure M, Ester E, et al. Minerva Urol Nefrol. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member. Cancer. Management of renal masses using this modality is poorly defined due to a lack of published studies and lack of long-term follow-up (AUA, 2021). Required ultrasound or colonoscopy for select adult patients based on clinical scenario; Ultrasound-first approach for pediatric abdominal and pelvic pain . BJU Int. July 25, 2018. Updated September 20, 2021. AIUM-ACR-ACOG-SMFM-SRU Practice parameter for the performance of standard diagnostic obstetric ultrasound examinations. 2014; 2014:186782. While some trials using HIFU to treat pancreatic or liver cancer have shown some promising results, these trials have lacked a comparator group (Chen, 2015; Dupr, 2015; Shi, 2015; Sofuni, 2014). Palliative treatment: Treatment given for relief of symptoms and pain rather than attempting to cure. HIFU is a non-invasive ablative procedure which has the advantage of sparing surrounding tissue which may reduce postoperative morbidity and hasten recovery. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia . The Centers for Medicare and Medicaid Services (CMS) released an updated Relative Value file Jan. 5, that includes updated reimbursement for the neuromuscular ultrasound codes 76881, 76882 and 76883. AIUM Practice Parameter for the Performance of Detailed Second- and Third-Trimester Diagnostic Obstetric Ultrasound Examinations. The overall survival (OS) rate was 80%, the progression-free survival (PFS) rate was 94%, and the disease-specific survival rate was 97%. Updated Discussion and References section. 2016; 70(3):447-455. HIFU was comparable to the median survival in standard chemotherapy. Participants received either MRgFUS (n=112) or placebo (n=35) treatment. Pak J Pharm Sci. Indiana Medicaid provides coverage to pregnant women through two programs. CA/LG/Anthem PPO HSA/H 2000/3000/4000 20/40/73A3/01-23 Page 1 of 11 Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Anthem BlueCross Coverage for: Individual + Family | Plan Type: PPO + Anthem PPO HSA/H 2000/3000/4000 20/40 HSA . A total of 29 individuals underwent a follow-up biopsy, either at 12 months only, or at 12 and 36 months. . Management of prostate-specific antigen relapse in prostate cancer: a European Consensus. The limited examination of small biopsies as well as the lack of a reliable means of assessing some prognostic factors, such as potential lymphovascular invasion, may not provide adequate information for the determination of adjuvant systemic therapies. The authors reviewed 9 studies with a total of 167 participants. CO CHEIBA Custom Blue Priority PPO/BluePreferred Plan F 01 -20 1 of 15 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2021- 12/31/2021 Anthem Blue Cross and Blue Shield: Prime Blue Priority PPO Local recurrence of prostate cancer after external beam radiotherapy: early experience of salvage therapy using high-intensity focused ultrasonography. MPTAC review. 2011; 185(3):862-868. 2017. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan. Technology insight: High-intensity focused ultrasound for urologic cancers. : 20-EHC022. ISUOG Interim Guidance on ultrasound for Zika virus infection in pregnancy: information for healthcare professionals. CPT Only - American Medical Association, RAD.00038 Use of 3-D, 4-D or 5-D Ultrasound in Maternity Care, https://www.acog.org/-/media/project/acog/acogorg/clinical/files/committee-opinion/articles/2017/10/guidelines-for-diagnostic-imaging-during-pregnancy-and-lactation.pdf, https://www.acog.org/clinical/clinical-guidance/obstetric-care-consensus/articles/2018/12/placenta-accreta-spectrum, https://www.acog.org/clinical/clinical-guidance/practice-bulletin, https://www.smfm.org/publications/220-acog-smfm-joint-practice-advisory-interim-guidance-for-care-of-obstetric-patients-during-a-zika-virus-outbreak, https://www.acr.org/-/media/ACR/Files/Practice-Parameters/US-OB.pdf, https://acsearch.acr.org/docs/69465/Narrative/?_ga=2.211725906.656052169.1601908671-191399006.1564351312, https://acsearch.acr.org/docs/3102400/Narrative/, https://www.aium.org/resources/guidelines/obstetric.pdf, https://www.aium.org/resources/statements.aspx, https://www.aium.org/resources/guidelines.aspx, https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf, https://www.cdc.gov/zika/hc-providers/types-of-tests.html, https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/ncd103c1_part4.pdf, https://www.acog.org/Patients/FAQs/Routine-Tests-During-Pregnancy, https://www.cdc.gov/ncbddd/birthdefects/diagnosis.html, https://www.cdc.gov/zika/prevention/index.html, https://medlineplus.gov/ency/presentations/100197_1.htm. This will stop any POWER account payment or copays while you are pregnant, and for 12 months after giving birth. The authors reported that salvage TULSA was technically feasible and showed encouraging early results but have not been compared to standard therapy. TULSA is considered not medically necessary for any indication, including but not limited to prostate cancer. Rockville (MD): Agency for Healthcare Research and Quality (US); 2020 Sep. Report No. 2006b; 97(1):56-61. But in general, know that most plans cover: STD testing; Rh incompatibility testing; Prenatal vitamins; Gestational diabetes testing; Breastfeeding counseling and equipment; Post-birth birth control; Birth; Medical coverage of any complications; Dependent Care Accounts Medical Policy & Technology Assessment Committee (MPTAC) review. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Temperatures within the targeted area increase to 60-95C, which destroys the targeted tissue without damaging the adjacent tissue. June 7, 2018. Ahmed HU, Cathcart P, McCartan N, et al. 2013; 63(2):395-398. In addition, eligible participants reported a numerical rating scale (NRS) pain score of 4 or greater in spite of maximal pain medication therapy, and a score of 7 or less on the Mirels fracture risk scale. Eur Urol. Available at: Magnetic Resonance guided Focused Ultrasound Surgery System (MRgFUS) ExAblate Model 2000/2100. Can J Urol. There are currently two ultrasound ablative techniques. 2009; 101(1):19-26. The feasibility and safety of high-intensity focused ultrasound as salvage therapy for recurrent prostate cancer following external beam radiotherapy. MPTAC review. MRI-TULSA resulted in an 88% reduction of viable prostate tissue volume. August 15, 2019. ACOG Practice Bulletin Number 171. Evaluate for threatened, incomplete, or missed abortion; Non-reassuring fetal heart rate monitoring; Assess amniotic fluid volume in post-term gestation. Clin Orthop Relat Res. Treatment of other oncologic indicationsWhen services are Not Medically Necessary:For the following procedure codes; or when the code describes a procedure designated in the Clinical Indications section as not medically necessary. When services are Not Medically Necessary:For the procedure and diagnosis codes listed above when criteria are not met or for all other diagnoses not listed; or when the code describes a procedure or situation designated in the Clinical Indications section as not medically necessary. Magnetic resonance imaging-guided transurethral ultrasound ablation of prostate cancer. 2012; 118(12):3071-3078. HAIFA, Israel - MIAMI, Florida (December 22, 2022) Insightec , a global healthcare company dedicated to using acoustic energy to transform patient care, announced today that Anthem is the third national payor to cover MR-guided Focused Ultrasound for treating medication-refractory Essential Tremor. In 2016, ACOG and the SMFM released a practice advisory regarding the current information and recommendations regarding the Zika virus. High-intensity focused ultrasound and localized prostate cancer: efficacy results from the European multicentric study. Medicare Supplement Plan F is great because it provides the most coverage of the 10 currently available MedSup plans. That coverage comes at a cost, however; specifically, Plan F is the most expensive of all the MedSup policies on the market today. Available at: Centers for Disease Control and Prevention (CDC). Alternatively, commercial or FEP plans or lines of business which determine there is not a need to adopt the guideline to review services generally across all providers delivering services to Plans or line of businesss members may instead use the clinical guideline for provider education and/or to review the medical necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in some other manner. Updated Discussion, References and Websites for Additional Information sections. The value of adding a universal booking scan to an existing protocol of routine mid-gestation ultrasound scan. Breast MRI costs an average $615 under Medicare . Prostate cancer is the most commonly diagnosed cancer in men, accounting for 19% of all new cancer cases. Assess vaginal bleeding of undetermined etiology; Assess abdominal or pelvic pain of undetermined etiology; Evaluation of fetal condition in late registrants for prenatal care; History of unexplained fetal demise in a previous pregnancy; Assess the fetus in cases with maternal risk factors such as family history of congenital abnormalities, chronic systemic disease (including but not limited to, hypertension, diabetes or sickle cell disease), preeclampsia, substance abuse or hyperemesis gravidarum; Assessment of fetus after abnormal serum Alpha Fetal Protein (AFP), serum screen or multiple analyte serum screen, or cell-free fetal deoxyribonucleic acid (DNA) screening for aneuploidy; Suspected ectopic pregnancy or hydatidiform mole, and to follow hydatidiform mole; Assess the fetus in cases of Rhesus (Rh) isoimmunization and other causes of fetal hydrops; Provide guidance for other testing, such as amniocentesis, chorionic villus sampling, and cordocentesis or procedures such as intrauterine blood transfusions or other in-utero fetal therapeutic procedures. Nair SM, Hatiboglu G, Relle J, et al. Clin Genitourin Cancer. Prostate Cancer. . New reimbursement policy: Maternity Services and Multiple Delivery (Professional) Beginning with dates of service on or after December 1, 2019, Anthem's current Routine Obstetrics policy will be retired and will be replaced by the new Maternity Services policy and the new Multiple Delivery policy. Eur Urol. Palliative Care. However, EBRT has been shown to be ineffective in approximately 20-30% of cases and pain recurs in 27% of the treated population (Liberman, 2009). There are concerns about inconsistent treatment coverage within renal masses resulting in incomplete ablation. High-intensity focused ultrasound for treatment of pancreatic cancer: a systematic review. HIFU therapy was included in a comparative effectiveness review of clinically localized prostate cancer treatments (Dahm, 2020). Salvage high-intensity focused ultrasound (HIFU) for locally recurrent prostate cancer after failed radiation therapy: Multi-institutional analysis of 418 patients. Pregnant Women. In those individuals who reported a decrease in pain levels, 50% (9/18) reported complete relief of pain, with 52% reporting significant pain relief beginning 3 days post treatment. 2011; 3(3):329-338. J Urol. In 2021, Nair and colleagues reported the 3-year outcomes of the participants in the Chin study. Sofuni A, Moriyasu F, Sano T, et al. Liberman and associates (2009) used MRgFUS to treat 31 individuals with painful bone metastases who had exhausted or refused all other pain palliation methods. Nat Rev Clin Oncol. Systematic review of innovative ablative therapies for the treatment of locally advanced pancreatic cancer. The authors noted these results compared well to the radiation therapy complication rate. Int J Urol. Updated Discussion/General Information, References and Websites for Additional Information sections. These studies have a number of methodological limitations, including a lack of randomization of participants, a lack of a comparator group and limited follow-up for oncologic outcomes. There was 1 in-field and 2 out-of-field recurrences reported at that time. Available at: Centers for Disease Control and Prevention (CDC). 2016; 47(4):530-532. Results indicated that median survival in RFA, IRE and SBRT was more favorable compared to HIFU. The 2018 ACR/AIUM/ACOG/SMFM/SRU practice parameter notes Obstetrical ultrasound should be performed only when there is a valid medical reason, and the lowest possible ultrasonic exposure settings should be used to gain the necessary diagnostic information.. Unlisted procedure, breast [when specified as destruction of breast tissue by high intensity focused ultrasound], Unlisted procedure, urinary system [when specified as transurethral MRI directional ultrasound ablation of prostate tissue (TULSA)], Ablation of malignant prostate tissue, transrectal, with high intensity-focused ultrasound (HIFU), including ultrasound guidance. CA/SG/Anthem Platinum PPO 15/250/10%/6BPB/01-22 Page 1 of 13 Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered ServicesCoverage Period: 01/01/2022 - 12/31/2022 Anthem BlueCross Coverage for: Individual + Family | Plan Type: PPO Anthem Platinum PPO 15/250/10% The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. Available at: Second and third trimester screening for fetal anomaly. The identified primary endpoint was the improvement in self-reported pain score without an increase in pain medication utilization at 3 months. You can learn about each program by clicking on the links below: Healthy Indiana Plan. 2014; 106(5). Bone metastasis: When cancer cells have broken off from the primary tumor and have settled and started growing on bones. Mol Urol. Focal therapy for localized prostate cancer: a phase I/II trial. Focal high intensity focused ultrasound of unilateral localized prostate cancer: a prospective multicentric hemiablation study of 111 patients. November 6, 2015. Invest Radiol. Li CC, Wang YQ, Li YP, Li XL. Hinyokika Kiyo. American College of Obstetricians and Gynecologists (ACOG). Re: Salvage high-intensity focused ultrasound for patients with recurrent prostate cancer after brachytherapy. We are now accepting all Anthem Blue Cross Blue Shield patients. New 2020. In the 25 participants that were able to tolerate a complete treatment, 72% (18/25) reported significant pain reduction of at least 2 points on the VAS scale, 24% (6/25) reported no reduction in pain and 4% (1/25) reported an increase in pain levels. Prostate Cancer. For pregnant women with laboratory evidence of Zika infection, ultrasound to evaluate for fetal abnormalities consistent with congenital Zika virus syndrome is recommended. 2015; 2015(6):CD001451. . Principles and results of high-intensity focused ultrasound for localized prostate cancer. Uchida T, Baba S, Irie A, et al. Individuals received either whole gland (n=8) or partial (n=8) ablation. Anthem becomes the third national payor to cover the treatment after Aetna and Blue Cross Blue Shield Association gave it positive coverage decisions in April 2021 and August 2018,. Zika virus was first reported in South America in May 2015 and since that time has now appeared in the United States. MPTAC review. Salvage magnetic resonance imaging-guided transurethral ultrasound ablation for localized radiorecurrent prostate cancer: 12-month functional and oncological results. 15727 Anthem Pkwy, Suite 600 . Real-time magnetic resonance-guided high-intensity focused ultrasound focal therapy for localised prostate cancer: preliminary experience. Updated Description, Discussion and References sections. Assess significant discrepancy between uterine size and dates; Follow-up for observation of identified fetal or cord anomaly; Evaluate suspected fetal growth abnormality (either growth restriction or macrosomia), and to follow proven or suspected intrauterine growth restriction; Confirm suspected or follow confirmed diagnosis of polyhydramnios or oligohydramnios; Estimate fetal weight or presentation in premature rupture of membranes or preterm labor; Serial evaluation of fetal growth in multi-fetal pregnancy. Approximately 30% of all individuals with cancer develop metastatic bone lesions and 50-75% of these individuals report significant pain. Evaluation of quality of life outcomes following palliative treatment of bone metastases with magnetic resonance-guided high intensity focused ultrasound: an international multicentre study. The clearance was based upon the Ablatherm device as the predicate device. Screening for Fetal Aneuploidy. At various gestational ages, ultrasound examination is an accurate method of determining gestational age, fetal number, viability, and placental location, and it is recommended for all pregnant patients. The pain severity score was significantly reduced from a baseline mean of 7.1 (Standard Deviation[SD] 2.08) (4-10; 95% confidence interval [CI], 6.07-8.15), to 2.5 (SD 1.4) (0-5; 95% CI, 1.81-3.2) at 1 month. Peek MC, Ahmed M, Napoli A, et al. These options carry their own risks and side effects. Crouzet S, Blana A, Murat FJ, et al. Placenta Accreta Spectrum. Kanthabalan A, Peters M, Van Vulpen M, et al. FAQ 133, July 2021. $0 plans in select areas. Eur Urology. Magnetic resonance imaging-guided transurethral ultrasound ablation of prostate tissue in patients with localized prostate cancer: a prospective Phase 1 clinical trial. Ultrasound is currently being used as a therapeutic treatment, for example, lithotripsy to disintegrate kidney stones. June 2021. Clarification to Not Medically Necessary Statement. Available at. 2000; 14(6):519-528. J Urol. TULSA was developed as an alternative method of prostate tissue ablation. Focal therapy for localised unifocal and multifocal prostate cancer: a prospective development study. High intensity focused ultrasound ablation for patients with inoperable liver cancer. Zika Virus. Ann Surg Oncol. Anthem has begun denying coverage for . Statement on Biological Effects of Ultrasound in Vivo. Reformatted Coding section. Mirels scoring system: A scoring system based upon lesion characteristics and pain levels used to classify pathologic fracture risk. Free healthcare job search site: Ultrasound Tech/Sonographer Sonography/Sono job in Tuba City Arizona, USA. The primary endpoint was achieved in 96% (110/115) of participants. Available at: Papageorghiou AT, Thilaganathan B, Bilardo CM, et al. This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for Ultrasound, Soft Tissues of Head and Neck. Correlation of prostate-specific antigen nadir and biochemical failure after high-intensity focused ultrasound of localized prostate cancer based on the Stuttgart failure criteria - analysis from the @-Registry. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Prostate cancer therapy with high-intensity focused ultrasound. CPT codes Dx codes 76801 76802 D25, D25.0, D25.1, D25.2, D25.9, O0900, O0901, O0902, O0903, O09511, O09512, One ultrasound of a pregnant uterus per member, per routine course of care; Estimate gestational age for individuals with uncertain clinical dates. For appeals related to well-being incentive credits, Updated grammar in medically necessary statement regarding maternal risk factors from including but not limited to, hypertension, diabetes, sickle cell disease preeclampsia), substance abuse, or hyperemesis gravidarum to including but not limited to, hypertension, diabetes or sickle cell disease), preeclampsia, substance abuse or hyperemesis gravidarum. The most commonly reported complications included Stress 1 urinary incontinence (18.7%), followed by obstruction of the bladder outlet (16.6%), and acute urinary retention (7.6%). Anthem isn't the only insurer trying to find a way around hospitals' steeper costs for outpatient imaging, says Lea Halim, a senior consultant at the Advisory Board, a health care research and. Updated References section. Bone pain is a common complaint for individuals with metastatic cancer to the bone. 2010; 468(10):2825-2827. Updated Coding section with 10/01/2022 ICD-10-CM changes; added O35.00X0-O35.9XX9 replacing O35.0XX0-O35.9XX9. Zhang M, Liu L, Wang J, et al. Pain palliation in patients with bone metastases using magnetic resonance-guided focused ultrasound with conformal bone system: a preliminary report. There were no treatment-related AEs. Guideline for the management of clinically localized prostate cancer: 2007 update. Magnetic resonance imaging-guided transurethral ultrasound ablation in patients with localised prostate cancer: 3-year outcomes of a prospective Phase I study. CT, digital radiography, ultrasound, mammography and DEXA equipment at each of our outpatient centers. Updated Discussion/General Information, Coding and Reference sections. Yutkin V, Ahmed HU, Donaldson I, et al. -12/31/2022 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: HMO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan.The SBC shows you how you and the plan would share the cost for covered health care services. Rischmann P, Gelet A, Riche B, et al. Ultrasound imaging can be used after delivery to evaluate abnormalities of the reproductive and adjacent structures. Reapproved June 16, 2020. Renal mass and localized renal cancer: Evaluation, management, and follow-up: AUA guideline. The bone metastases arose from a variety of primary tumors including renal, colorectal, lung, breast and prostate. ACOG Practice Bulletin Number 229. Urol Oncol. 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