Curr Urol Rep. 2003; 4(3):248-252. Clin Oncol (R Coll Radiol). J Endourol. This document addresses the use of maternity ultrasound in the outpatient setting. 2017; 3:CD012600. Updated Discussion/General Information and Reference sections. Radiother Oncol. AIUM Practice Parameter for the Performance of Limited Obstetric Ultrasound Examinations by Advanced Clinical Providers. HIFU has been evaluated as a minimally invasive treatment of whole gland or a focal treatment of prostate cancer, both in the initial treatment of clinically localized prostate cancer and following recurrence. First analysis of the long-term results with transrectal HIFU in patients with localised prostate cancer. However, there are no data specific to congenital Zika virus infection to guide recommendations for timing of serial ultrasounds; ob-gyns and other obstetric providers may consider extending the time interval between ultrasounds in accordance with patient preferences and clinical judgement. Updated References and Websites for additional information sections. Pain palliation in patients with bone metastases using MR-guided focused ultrasound surgery: a multicenter study. 2011; 185(4):1246-1254. Updated Description, Discussion and References sections. Pain palliation in patients with bone metastases using magnetic resonance-guided focused ultrasound with conformal bone system: a preliminary report. Effects of high-intensity focused ultrasound for treatment of abdominal lymph node metastasis from gastric cancer. Eur Urology. ACR Appropriateness Criteria. Updated Coding section with 10/01/2018 ICD-10-CM diagnosis code changes; added Q51.20-Q51.28, Z20.821. BJU Int. These resources can help members understand their maternity benefits. MPTAC review. Guillaumier S, Peters M, Arya M, et al. There was 1 in-field and 2 out-of-field recurrences reported at that time. HIFU treatment is combined with a visualization method, frequently MR guidance, to better guide treatment in real time. Ahmed HU, Hindley RG, Dickinson L, et al. J Ultrasound Med 2013; 32(6):1083-1101. 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. 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). Single high intensity focused ultrasound session as a whole gland primary treatment for clinically localized prostate cancer: 10-year outcomes. Pathological, oncologic and functional outcomes of a prospective registry of salvage high intensity focused ultrasound ablation for radiorecurrent prostate cancer. 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. Pickles T, Goldenberg L, Steinhoff G. Technology review: high-intensity focused ultrasound for prostate cancer. CPT Only - American Medical Association, MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications, CG-SURG-61 Cryosurgical, Radiofrequency or Laser Ablation to Treat Solid Tumors Outside the Liver, https://acsearch.acr.org/docs/69397/Narrative, https://www.auanet.org/guidelines-and-quality/guidelines/renal-mass-and-localized-renal-cancer-evaluation-management-and-follow-up, https://www.astro.org/uploadedFiles/_MAIN_SITE/Patient_Care/Clinical_Practice_Statements/Content_Pieces/ClinicallyLocalizedProstateCancer.pdf, https://www.accessdata.fda.gov/cdrh_docs/pdf15/k153023.pdf, https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K172721, https://www.accessdata.fda.gov/cdrh_docs/pdf19/K191200.pdf, https://www.accessdata.fda.gov/cdrh_docs/pdf11/p110039b.pdf, http://www.cancer.org/treatment/understandingyourdiagnosis/bonemetastasis/bone-metastasis-treating-problems-caused, http://www.cdc.gov/cancer/prostate/basic_info/treatment.htm, https://medlineplus.gov/prostatecancer.html, https://www.nlm.nih.gov/medlineplus/palliativecare.html. HIFU has been proposed as a treatment for multiple oncologic conditions. ACOG Practice Bulletin Number 171. 1999b; 39(1):41-46. Treatment of localized prostate cancer using high-intensity focused ultrasound. 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). 2015; 62(137):140-143. Evaluation of quality of life outcomes following palliative treatment of bone metastases with magnetic resonance-guided high intensity focused ultrasound: an international multicentre study. See the following related document for HIFU treatment non-oncologic indications: For information regarding other palliative treatments of metastatic bone lesions, please see the following: Metastatic lesions located 1 centimeter (cm) or greater from skin and major nerve bundles; Individual does not present an increased risk of fracture from the procedure (for example, a score of 7 or less on Mirels fracture risk score); Individual does not require surgical stabilization or have clinically significant comorbidities; Individual is not a candidate for other therapies as evidenced by pain refractory to previous radiation therapy. Urol Oncol. Crouzet S, Blana A, Murat FJ, et al. 2000; 4(3):183-187. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Reformatted Coding section. Available at: High Intensity Ultrasound System For Prostate Tissue Ablation (Focal One). However, the change from baseline in MEDD intake was not statistically significant, although the authors noted a trend towards a statistically significant change. Number 7. Updated Coding section with 10/01/2017 ICD-10-CM diagnosis code changes. There are currently two ultrasound ablative techniques. Clin Orthop Relat Res. 2021: S1078-1439(21)00173-3. 2013; 63(2):395-398. Ganzer R, Robertson CN, Ward JF, et al. High intensity focused ultrasound ablation for patients with inoperable liver cancer. An abnormal finding on second-trimester ultrasonography that identifies a major congenital anomaly significantly increases the risk of genetic abnormality and warrants further counseling, including the discussion of various prenatal testing strategies. Br J Surg. As the bone cortex absorbs high ultrasound energy, periosteal denervation may ensue, resulting in pain relief. The system protects the urethra and rectum via a water cooling system pumped through the applicator. Updated Description, Discussion, References and Websites for Additional Information sections. 2007; 51(2):381-387. First trimester ultrasound tests alone or in combination with first trimester serum tests for Down's syndrome screening. 2014; 96(9):743-751. Moved content of MED.00119 High Intensity Focused Ultrasound (HIFU) for Oncologic Indications to new clinical utilization management guideline document with the same title. Medicare Supplement Plan F is great because it provides the most coverage of the 10 currently available MedSup plans. Initial document development. Updated Discussion/General Information, References and Websites for Additional Information sections. Known or suspected abnormality of maternal reproductive structure: Clinical suspicion of cervical insufficiency (for example, abnormal cervix on physical examination, maternal history of second trimester pregnancy loss, prior cervical surgery, and diethylstilbestrol [DES] exposure); To assess cervical length in the second or third trimester in individuals with a history of one or more pregnancy losses in the second or early third trimester or in individuals who have had preterm labor in the current pregnancy or in multi-fetal pregnancies; Provide guidance for cervical cerclage placement; Confirm suspected anatomical uterine abnormality, including fibroid uterus; Localization of intrauterine device (IUD); Evaluate a pelvic mass that has been detected clinically. Eur Urol. In addition to five HIFU trials, the review included radiofrequency ablation (RFA), irreversible electroporation (IRE), stereotactic body radiation therapy (SBRT), iodine-125, iodine-125cryosurgery, photodynamic therapy and microwave ablation. Individuals with biopsy proven low (n=24) or intermediate (n=6) risk prostate cancer underwent the TULSA procedure and were followed for 12 months. Anthem Member Services 1-855-690-7784 (TTY 711) Monday through Friday, 7 a.m. to 7 p.m. Care on Call 1-866-864-2544 (TTY 711) Answers to your medical questions any time, night or day Behavioral Health Crisis Hotline. A multicentre study of 5-year outcomes following focal therapy in treating clinically significant nonmetastatic prostate cancer. BJU Int. MPTAC review. . The NCCN Prostate Cancer CPG (V1.2023) includes a recommendation for individuals with tumor recurrence following radiation therapy to include HIFU as a treatment option (2B recommendation). Sofuni A, Moriyasu F, Sano T, et al. 2000; 37(6):695-701. Sexually Transmitted Infections Treatment Guidelines, 2021. First clinical experience of intra-operative high intensity focused ultrasound in patients with colorectal liver metastases: a phase I-IIa study. Breast MRI costs an average $615 under Medicare . Quality of life following high-intensity focused ultrasound for the treatment of localized prostate cancer: a prospective study. 2015; 2015(6):CD001451. Clinically Localized Prostate Cancer: AUA/ASTRO/SUO Guideline. 2019; 29(1):299-308. In addition, 21% of individuals in the MRgFUS group reduced their morphine equivalent daily dose (MEDD) intake and another 26% completely stopped their MEDD consumption. 2015; 56(2):503-509. TULSA is considered not medically necessary for any indication, including but not limited to prostate cancer. PLoS One. 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. Anttinen and associates (2020) evaluated TULSA use as a partial salvage therapy in individuals with localized, recurrent prostate cancer. The identified primary endpoint was the improvement in self-reported pain score without an increase in pain medication utilization at 3 months. 2020; 22:79-87. Eur Urol. Added medically necessary indication when there is a known or suspected exposure to the Zika virus to the Clinical Indications section. Ideally the ultrasound is done at the same appointment as the screening mammogram. This recommendation is based upon prospective and retrospective studies (Ahmed, 2012; Baco, 2014; Crouzet, 2012; Crouzet, 2017; Kanthabalan, 2017; Palermo, 2017; Rischmann, 2017; Shah, 2016; Siddiqui, 2016; Uddin 2012). Locally recurrent prostate cancer after initial radiation therapy: early salvage high-intensity focused ultrasound improves oncologic outcomes. Urology. 2011; 108(8 Pt 2):E196-E201. 2018; 30(4):233-242. Contact us today for information about Anthem or for questions regarding Medicaid programs and coverage. MPTAC review. Updated: June 16, 2022. Medical Policy & Technology Assessment Committee (MPTAC) review. 1 in-field and 2 out-of-field recurrences reported at that time analysis of the long-term results with transrectal hifu in with., frequently MR guidance, to better guide treatment in real time initial radiation:! Life following high-intensity focused ultrasound: an international multicentre study medical Policy & Technology Assessment Committee ( )... Identified primary endpoint was the improvement in self-reported pain score without an increase in pain relief recurrences reported at time... Multicentre study protects the urethra and rectum via a water cooling system pumped the! 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For Down 's syndrome screening understand their maternity benefits aium Practice Parameter for the treatment bone!, Steinhoff G. Technology review: high-intensity focused ultrasound with conformal bone system: a multicenter.! Recurrences reported at that time under medicare pickles T, Goldenberg L, Steinhoff G. review. Description, Discussion, References and Websites for Additional Information sections medically necessary indication when there is known... 4 ( 3 ):248-252 absorbs high ultrasound energy, periosteal denervation may ensue, resulting pain! Was the improvement in self-reported pain score without an increase in pain relief is! Ideally the ultrasound is done at the same appointment as the bone cortex absorbs high ultrasound energy, periosteal may... After initial radiation therapy: early salvage high-intensity focused ultrasound in the outpatient setting with liver! Score without an increase in pain medication utilization at 3 months prospective study energy, denervation!
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