anthem ultrasound coverage

Previously, this recommendation was graded as a 2A. There were no reported treatment related severe adverse events (AEs). The feasibility and safety of high-intensity focused ultrasound as salvage therapy for recurrent prostate cancer following external beam radiotherapy. The current evidence does not show that clinical outcomes of those undergoing TULSA is similar to those undergoing established alternatives. Zika Virus. It is likely that both of these treatment effects contribute to pain relief. The resulting heat and cavitation destroys the targeted tissue. CA/IND/Anthem Silver 94 HMO/657X/01-22 Page 1 of 11 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: HMO Anthem Silver 94 HMO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The use of HIFU in the setting of breast cancer treatment may not allow for an adequate collection of tumor specimens to evaluate the tumor histopathology. Prostate Cancer Prostatic Dis. Added medically necessary indication when there is a known or suspected exposure to the Zika virus to the Clinical Indications section. Available at: Papageorghiou AT, Thilaganathan B, Bilardo CM, et al. 2014; 7(4):270-281. 2006a; 13(3):228-233. Grade 3 (n=1) and grade 2 (n=3) AEs related to urinary retention and urinary tract infection were reported. Hinyokika Kiyo. This guideline was reviewed and validated in 2011. You can choose your preferred appointment time on our website, www.ultrasound-first.com, or you can call Lexie at the office (314-782-2034) if you need help or have any questions. Focused ultrasound for the treatment of bone metastases: effectiveness and feasibility. HIP Maternity will cover enhanced benefits . 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. Bone pain is a common complaint for individuals with metastatic cancer to the bone. Before you decide to pass on Plan F, though, do your due diligence and see how much the insurance . August 15, 2019. The sound wave echoes are recorded and displayed as a real-time visual image. Bonekamp and associates (2019) performed a quantitative analysis of viable prostate tissue volume reduction at 12 months post-procedure. Available at: U.S. National Library of Medicine. 2013; 63(2):395-398. Control of prostate cancer by transrectal HIFU in 227 patients. American College of Radiology (ACR). Uddin Ahmed H, Cathcart P, Chalasani V, et al. The study has several methodological flaws, including lack of a comparison group, and uncertainty regarding the percentage of subjects who completed the follow-up period. Book an appointment today! 2021; 35(4):497-505. Transrectal high-intensity focused ultrasound for treatment of patients with stage T1b-2n0m0 localized prostate cancer: a preliminary report. There are currently more than 125 Treatment Centers around the world using Insightec's Exablate Neuro platform to treat Essential Tremor. A second systemic review in which HIFU was compared to other ablative therapies in the treatment of locally advanced pancreatic cancer was done by Rombouts and colleagues (2015). Napoli A, Anzidei M, De Nunzio C, et al. Approximately 30% of all individuals with cancer develop metastatic bone lesions and 50-75% of these individuals report significant pain. 2016; 19(3):311-316. In Ohio: Community Insurance Company. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card. 2021: S1078-1439(21)00173-3. Indiana Medicaid for Members. Find a doctor near you. Pain severity was measured using a 10-point pain scale questionnaire. 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. AIUM-ACR-ACOG-SMFM-SRU Practice parameter for the performance of standard diagnostic obstetric ultrasound examinations. Following treatment, no residual tumor was found in 46.2% of cases. 2015; 56(2):503-509. High intensity focused ultrasound as first line salvage therapy in prostate cancer local relapse after radical prostatectomy: 4-year follow-up outcomes. Providers are responsible for billing the appropriate CPT code, modifier, and diagnosis combinations. December 2016. No ionizing radiation (x-ray) is used in ultrasound imaging. 2017; 71(2):267-273. Ahmed HU, Cathcart P, McCartan N, et al. Hepatogastroenterology. Pain palliation for localized metastatic bone pain. The bone metastases arose from a variety of primary tumors including renal, colorectal, lung, breast and prostate. 2004; 63(4):625-629. TULSA was developed as an alternative method of prostate tissue ablation. J Evid Based Med. Find job postings in CA, NY, NYC, NJ, TX, FL, MI, OH, IL, PA, GA, MA, WA, UT, CO, AZ, SF Bay Area, LA County, USA, North America / abroad. 2010; 468(10):2825-2827. Five years experience of transrectal high-intensity focused ultrasound using the Sonablate device in the treatment of localized prostate cancer. MPTAC review. Uchida T, Tomonaga T, Kim H, et al. Replaced term women with individual within clinical indications. check_circle Item Saved! Updated Coding section with 10/01/2017 ICD-10-CM diagnosis code changes. Anttinen and associates (2020) evaluated TULSA use as a partial salvage therapy in individuals with localized, recurrent prostate cancer. 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). Crouzet and colleagues (2014) conducted a large prospective case series (n=1002) to evaluate rates of survival and morbidity over the long term in subjects treated with HIFU (Ablatherm) for localized disease. Limani K, Aoun F, Holz S, et al. P110039. Alldred SK, Takwoingi Y, Guo B, et al. Mirels scoring system: A scoring system based upon lesion characteristics and pain levels used to classify pathologic fracture risk. Federal and State law, as well as contract language, and Medical Policy take precedence over Clinical UM Guidelines. Single high intensity focused ultrasound session as a whole gland primary treatment for clinically localized prostate cancer: 10-year outcomes. American Urological Association (AUA). Of note, 65.7% (23/35) of individuals in the placebo group did not complete the 3-month follow-up compared to approximately 21% (26/112) of the MRgFUS group. 2000; 37(6):695-701. 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. The PSA decreased from a median of 6.26 to 0.53 at 12 months. Focal high intensity focused ultrasound of unilateral localized prostate cancer: a prospective multicentric hemiablation study of 111 patients. Guideline for the management of clinically localized prostate cancer: 2007 update. Bone metastasesWhen services may be Medically Necessary when criteria are met: Unlisted procedure, musculoskeletal system, general [when specified as high intensity focused ultrasound ablation for pain palliation for bone metastases], Focused ultrasound ablation/therapeutic intervention, other than uterine leiomyomata, with magnetic resonance (MR) guidance. The TULSA-PRO (Profound Medical Corp., Fort Myers, FL) received 510(k) clearance by the FDA in 2019. Available at. 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. On October 9, the FDA granted de novo clearance to SonaCare Medical, LLC (Charlotte, NC) to market the Sonablate 450 for prostate tissue ablation. Practice Advisory Interim Guidance for Care of Obstetric Patients During a Zika Virus Outbreak. In 2015, The U.S. Food and Drug Administration (FDA) approved two devices for use in prostate cancer. Technology insight: High-intensity focused ultrasound for urologic cancers. Systematic review of high-intensity focused ultrasound ablation in the treatment of breast cancer. 2011; 3(3):329-338. 2006b; 97(1):56-61. One of the largest of these studies was conducted by Ganzer and colleagues (2011). October 2016. Prostate Cancer. Participants received either MRgFUS (n=112) or placebo (n=35) treatment. 2018. November 17, 2019. AIUM Practice Parameter for the Performance of Detailed Diagnostic Obstetric Ultrasound Examinations Between 12Weeks 0Days and 13Weeks 6Days. 2022 Prenatal ultrasound diagnosis (Dx) codes Please note that this information is a guideline. Kenkhuis MJA, Bakker M, Bardi F, ET AL. Eur Urol Open Sci. Thuroff S, Chaussy C, Vallancien G, et al. Klotz L, Pavlovich CP, Chin J, et al. Twelve-month prostate volume reduction after MRI-guided transurethral ultrasound ablation of the prostate. Reformatted Coding section and updated with 01/01/2021 CPT and HCPCS changes, added 55880 to replace NOC code; code C9747 deleted 12/31/2020. Ultrasound abnormalities have been detected in the fetus from 2 to 29 weeks after symptom onset, and therefore, insufficient data are available to define the optimal timing between exposure and initial sonographic screening. When high-intensity ultrasound waves are used in place of low-intensity, body tissue absorbs, rather than reflects the energy. This document does not address nuchal translucency. June 7, 2018. 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. NCCN Clinical Practice Guidelines in Oncology. The gestational sac is examined for the presence of yolk sac and embryo/fetus (a fetus is generally defined as greater than or equal to 10 weeks gestational age). Note: Please see the following related document for additional information: Maternity ultrasound is considered medically necessary for any of the following: Maternity ultrasound is considered not medically necessary for: The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. 2000; 14(6):519-528. 2008; 102(7):786-792. 2012; 13(6):622-632. In the December 2013 issue of Network Update, you were notified of the following: For claims with dates of service on or after March 17, 2014, Anthem Blue Cross and Blue Shield (Anthem) in Indiana, Kentucky, Missouri, Ohio and Wisconsin (individually referred to herein as the Health Plan), will no longer reimburse CPT code 76942 (Ultrasonic . Bertrand AS, Iannessi A, Natale R, et al. 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. Updated Description, Discussion, References and Websites for Additional Information sections. CPT codes Dx codes 76801 76802 D25, D25.0, D25.1, D25.2, D25.9, O0900, O0901, O0902, O0903, O09511, O09512, Available at: Second and Third Trimester Vaginal Bleeding. Ahmed HU, Zacharakis E, Dudderidge T, et al. 2015; 102(3):182-193. Systematic review of innovative ablative therapies for the treatment of locally advanced pancreatic cancer. Elterman D, Li W, Hatiboglu G, et al. The mean reduction in the NRS score was significant between MRgFUS and placebo (3.6 3.1 versus 0.7 2.4). Joo B, Park MS, Lee SH, et al. Transrectal high-intensity focused ultrasound: minimally invasive therapy of localized prostate cancer. Two-year results of transurethral resection of the prostate versus four 'less invasive' treatment options. Reaffirmed October 2021. Post-treatment biopsies were available in 77% of subjects. 2017; 197(1):97-102. Taneja SS. In the first phase III study published, Hurwitz and colleagues (2014) conducted a randomized, placebo-controlled, single-blind, multicenter, pivotal trial which included 147 participants with bone metastases from breast, prostate, kidney, lung or other primary tumors. 2014; 114(4):532-540. BJU Int. Government Agency, Medical Society, and Other Authoritative Publications: Maternal UltrasoundObstetricPrenatalSonography. Gelet A, Chapelon JY, Poissonnier L, et al. 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. The current evidence is insufficient to support the use of HIFU as a generally accepted oncological treatment. Available at: High Intensity Ultrasound System for Prostate Tissue Ablation (TULSA-PRO System). Individuals with biopsy proven low (n=24) or intermediate (n=6) risk prostate cancer underwent the TULSA procedure and were followed for 12 months. Magnetic resonance-guided focused ultrasound for patients with painful bone metastases: phase III trial results. CA/IND/Anthem Silver 73 HMO/657G/01-22 Page 1 of 12 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: HMO Anthem Silver 73 HMO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. 2021; 205(3):769-779. Renal mass and localized renal cancer: Evaluation, management, and follow-up: AUA guideline. Removed ICD-9 codes from Coding section. Prenatal ultrasound-series. 2009; 101(1):19-26. Gardner TA, Koch MO. Ultrasound Tech in San Antonio, Texas, United States. These Medical Policies serve as guidelines for health care benefit coverage decisions, which may vary according to the different products and benefit plans offered by BCBSIL. The baseline median PSA of 7.6 ng/ml decreased to 0.23 ng/ml at 12 months follow-up. AIUM Practice Parameter for the Performance of Detailed Second- and Third-Trimester Diagnostic Obstetric Ultrasound Examinations. July 25, 2018. Rombouts SJ, Vogel JA, van Santvoort HC, et al. Clinically Localized Prostate Cancer: AUA/ASTRO/SUO Guideline. Search doctors, conditions, or procedures . Bone Metastases. Eur Urol. Int J Urol. 2004; 63(2):297-300. 2014; 106(5). 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. Pickles T, Goldenberg L, Steinhoff G. Technology review: high-intensity focused ultrasound for prostate cancer. J Endourol. 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. Gelet A, Chapelon JY, Bouvier R, et al. 2005; 4(3):187-192. Clarification to Not Medically Necessary Statement. MPTAC review. Reformatted Coding section. 399 reviews of Anthem Blue Cross "Poor reviews for Anthem's medical insurance coverage business, in particular, the medical insurance processing. BJU Int. J Natl Cancer Inst. Clin Orthop Relat Res. MPTAC review. The current standard treatment is external beam radiation therapy (EBRT). Effects of high-intensity focused ultrasound for treatment of abdominal lymph node metastasis from gastric cancer. Accessed on October 20, 2022. MPTAC review. 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