Added Websites for Additional Information section. Zip Code or City, State . Muto S, Yoshii T, Saito K, et al. 2018; 74(4):422-429. Revised title from High Intensity Focused Ultrasound (HIFU) for Oncologic Indications to Ultrasound Ablation for Oncologic Indications. Individuals received either whole gland (n=8) or partial (n=8) ablation. The current evidence is insufficient to support the use of HIFU as a generally accepted oncological treatment. When high-intensity ultrasound waves are used in place of low-intensity, body tissue absorbs, rather than reflects the energy. Find top doctors who perform Rectal Ultrasound near you in Anthem, AZ. Urology. Birth Defects Homepage: Diagnosis. Jawad MU, Scully SP. Five years experience of transrectal high-intensity focused ultrasound using the Sonablate device in the treatment of localized prostate cancer. 2021; 35(4):497-505. MedlinePlus. FAQ 133, July 2021. Therapies for clinically localized prostate cancer [Internet]. Available at: Papageorghiou AT, Thilaganathan B, Bilardo CM, et al. ACR Appropriateness Criteria. Ultrasound imaging can be used after delivery to evaluate abnormalities of the reproductive and adjacent structures. On October 9, the FDA granted de novo clearance to SonaCare Medical, LLC (Charlotte, NC) to market the Sonablate 450 for prostate tissue ablation. Step 1: Report your pregnancy to your health plan. Statement on Biological Effects of Ultrasound in Vivo. 2005; 51(10):651-658. J Endourol. Specific findings associated with congenital Zika syndrome include intracranial calcifications, microcephaly, ventriculomegaly, arthrogryposis; abnormalities of the corpus callosum, cerebrum, cerebellum, and eyes; and other brain abnormalities. Poissonnier L, Chapelon JY, Rouviere O, et al. 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. TULSA is considered not medically necessary for any indication, including but not limited to prostate cancer. 2015; 193(1):103-110. 2018. Siddiqui KM, Billia M, Arifin A, et al. 2009; 16(1):140-146. Reviewed and validity confirmed 2011. Zika virus was first reported in South America in May 2015 and since that time has now appeared in the United States. Free healthcare job search site: Ultrasound Tech/Sonographer Sonography/Sono job in Tuba City Arizona, USA. TULSA has been proposed as a localized treatment of unilateral intermediate risk prostate cancers in individuals not interested in active surveillance (Klotz, 2021). Updated September 20, 2021. 2004; 7(4):289-294. According to the FDA labeling, a nonunion is considered to be established when the fracture site shows no visibly progressive signs of healing. Replaced term women with individual within clinical indications. Matthew Thornton Health Plan, Inc./Anthem Blue Cross and Blue Shield Coverage for: Individual + Family | Plan Type: HMO Anthem Silver Pathway X Enhanced HMO 5500/20% S05 ($0 Preferred Virtual Care + $0 Select Drugs) The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. J Ultrasound Med 2013; 32(6):1083-1101. 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. Crouzet S, Blana A, Murat FJ, et al. 2021: S1078-1439(21)00173-3. 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. Updated Coding section with 10/01/2022 ICD-10-CM changes; added O35.00X0-O35.9XX9 replacing O35.0XX0-O35.9XX9. 2015 Mar;34(3):435-440. 2014; 65(5):907-914. The guideline addresses several non-extirpative therapies and concluded that these therapies, including HIFU, are investigational for the treatment of renal masses. Non-Contact Ultrasound Treatment for Wounds; Non-Oncologic Uses of Rituximab (Rituxan) Nutritional Treatment of Childhood Medical Conditions; Ophthalmologic Techniques for Evaluating Glaucoma; Optical Diagnostic Devices for Evaluating Skin Lesions Suspected of Malignancy ; Oral Lesion Identification System (ViziLite, Velscope) Nat Rev Clin Oncol. Chaussy C, Thuroff S, Rebillard X, Gelet A. As of January 10, 2022, through January 31, 2022, Anthem and its delegated entities will suspend select prior authorization requirements to allow healthcare providers to focus on caring for patients diagnosed with COVID-19. Our radiologists are among the most . 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. Napoli A, Anzidei M, De Nunzio C, et al. The system protects the urethra and rectum via a water cooling system pumped through the applicator. MR-guided focused ultrasound (MRgFUS) ablation for the treatment of nonspinal osteoid osteoma: a prospective multicenter evaluation. Kenkhuis MJA, Bakker M, Bardi F, ET AL. * From Jawad MU, Scully SP. High intensity focused ultrasound ablation for patients with inoperable liver cancer. NCCN Clinical Practice Guidelines in Oncology. AIUM Practice Parameter for the Performance of Detailed Diagnostic Obstetric Ultrasound Examinations Between 12Weeks 0Days and 13Weeks 6Days. New 2020. November 6, 2015. An obstetrical ultrasound in the second or third trimester includes an evaluation of fetal number, cardiac activity, presentation, amniotic fluid volume, placental position, fetal biometry, and an anatomic survey. 2000; 4(3):183-187. Review January 10, 2022. 2006a; 13(3):228-233. 2017; 71(2):267-273. Magnetic resonance imaging-guided transurethral ultrasound ablation in patients with localised prostate cancer: 3-year outcomes of a prospective Phase I study. J Ultrasound Med. Centers for Disease Control and Prevention (CDC). Breast MRI costs an average $615 under Medicare . There are a number of uncontrolled case series and prospective studies which address HIFU for prostate cancer (Ahmed, 2009, 2011, 2012; Beerlage, 1999b; Blana, 2004; Chaussy, 2001; Gelet, 2000; Gelet, 2004; Guillaumier; 2018; Lawrentschuk, 2011; Muto, 2008; Napoli, 2013; Poissonnier, 2007; Shoji, 2010; Thuroff, 2003; Uchida, 2002; Uchida, 2005; Uchida, 2006a; Uchida, 2006b; Zacharakis, 2008). 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. The majority of events were minor and reversible. Joo B, Park MS, Lee SH, et al. 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. Updated: June 16, 2022. In some states, insurance must cover . Updated Coding section with 10/01/2020 ICD-10-CM changes; added O99.891; removed Q51.20 deleted 09/30/2020. Cochrane Database Syst Rev. Magnetic resonance-guided focused ultrasound for patients with painful bone metastases: phase III trial results. J Evid Based Med. Albisinni S, Aoun F, Bellucci S, et al. In addition to the active and pending Medical Policies, BCBSIL has included policies which are under development or being revised. Magnetic resonance imaging-guided transurethral ultrasound ablation of prostate tissue in patients with localized prostate cancer: a prospective Phase 1 clinical trial. There are currently more than 125 Treatment Centers around the world using Insightec's Exablate Neuro platform to treat Essential Tremor. Available at: Dahm P, Brasure M, Ester E, et al. Eur Urol. Curr Urol Rep. 2003; 4(3):248-252. 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. Urology. Recommendations for the management of a pregnant individuals with suspected Zika virus infection include: The 2021 CDC guideline on the treatment of sexually transmitted infections includes management recommendations for individuals who are diagnosed with text in the second half of pregnancy. Single high intensity focused ultrasound session as a whole gland primary treatment for clinically localized prostate cancer: 10-year outcomes. check_circle Item Saved! Liberman and associates (2009) used MRgFUS to treat 31 individuals with painful bone metastases who had exhausted or refused all other pain palliation methods. Focal salvage therapy for localized prostate cancer recurrence after external beam radiotherapy: a pilot study. Bone metastases are common in breast and prostate cancer (Liberman, 2009). When services are Not Medically Necessary:For the procedure and diagnosis codes listed above when criteria are not met. This study was a retrospective case series involving 804 subjects who underwent HIFU and were included in an industry-sponsored registry. These options carry their own risks and side effects. Moved content of MED.00119 High Intensity Focused Ultrasound (HIFU) for Oncologic Indications to new clinical utilization management guideline document with the same title. Find a doctor near you. Routine ultrasound in late pregnancy (after 24 weeks' gestation). AIUM practice guideline for the performance of obstetric ultrasound examinations. ACOG Practice Bulletin Number 183, October 2017. Rischmann P, Gelet A, Riche B, et al. 1999b; 39(1):41-46. 2020; 22:79-87. 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. Pain palliation for localized metastatic bone pain Bone pain is a common complaint for individuals with metastatic cancer to the bone. Yutkin V, Ahmed HU, Donaldson I, et al. Cancer. 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. 2017. Sofuni A, Moriyasu F, Sano T, et al. Alldred SK, Takwoingi Y, Guo B, et al. Napoli A, Anzidei M, Marincola BC, et al. By March 2018, Anthem (Blue Cross/Blue Shield) will require that MR and CT scans considered "not medically necessary" be performed at freestanding medical imaging facilities in order to be covered. There is insufficient evidence to draw conclusions about the effect of HIFU on urinary incontinence, erectile dysfunction or fecal incontinence when compared to radical prostatectomy. The clearance was based upon the Ablatherm device as the predicate device. Effectiveness of 12-13-week scan for early diagnosis of fetal congenital anomalies in the cell-free DNA era. 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, respectively. 2009; 101(1):19-26. 2015; 56(2):503-509. 1999a; 54(2):273-277. We reserve the right to review and update Clinical UM Guidelines periodically. 2006b; 97(1):56-61. MPTAC review. 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 . Accessed on October 20, 2022. Focal salvage high-intensity focused ultrasound in radiorecurrent prostate cancer. Comprehensive medical coverage that covers many common services at no cost or for a low copay. 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 authors noted these results compared well to the radiation therapy complication rate. 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. June 2021. 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). Anthem BlueCross Coverage for: Individual + Family | Plan Type: HMO Anthem Value Ded HMO 750/25/40/25% The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. Rooms for rent in Bury flat and house shares - 3 currently available. . You should contact Anthem Blue Cross and Blue Shield directly to appeal denial of coverage for medical claims by calling 1855- -641-4862. Comparing high-intensity focal ultrasound hemiablation to robotic radical prostatectomy in the management of unilateral prostate cancer: a matched-pair analysis. 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. 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. 2007; 51(2):381-387. Last Revised March 16, 2022. U.S. Food and Drug Administration (FDA). Improved outcomes with advancements in high intensity focused ultrasound devices for the treatment of localized prostate cancer. Shi Y, Ying X, Hu X, et al. The focus of this study was the use of prostate specific antigen (PSA) as a predictor of disease-free survival after HIFU, not the outcomes related to HIFU treatment. PLoS One. December 2016. Updated Coding section to add ICD-10-CM diagnosis codes O09.00-O09.03, O09.811-O09.829. A statistically significant pain response was reported in 70.7% of this group. Added medically necessary indication when there is a known or suspected exposure to the Zika virus to the Clinical Indications section. BJU Int. 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. Ahmed HU, Hindley RG, Dickinson L, et al. Temperatures within the targeted area increase to 60-95C, which destroys the targeted tissue without damaging the adjacent tissue. Shoji S, Nakano M, Nagata Y, et al. 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,. World J Gastroenterol. Dupr A, Melodelima D, Prol D, et al. August 27, 2020. Early prospective studies evaluating MRgFUS reported promising results. J Urol. CPT codes Dx codes 76801 76802 D25, D25.0, D25.1, D25.2, D25.9, O0900, O0901, O0902, O0903, O09511, O09512, Salvage high-intensity focused ultrasound (HIFU) for locally recurrent prostate cancer after failed radiation therapy: Multi-institutional analysis of 418 patients. Blana A, Murat FJ, Walter B, et al. Eur Urol. Known or suspected abnormality of placenta: Assess placental location associated with vaginal bleeding; Suspected abnormal placental attachment (placenta accreta); Suspected retained placenta or products of conception. . Insurance coverage for whole-breast ultrasound is evolving. Taneja SS. Effects of high-intensity focused ultrasound for treatment of abdominal lymph node metastasis from gastric cancer. In November, the FDA approved the use of Ablatherm (Maple Leaf; Toronto, Canada) to treat prostate cancer in individuals who previously failed radiation therapy. Accessed on September 13, 2022. Rockville (MD): Agency for Healthcare Research and Quality (US); 2020 Sep. Report No. MPTAC review. Available at: American Cancer Society. First analysis of the long-term results with transrectal HIFU in patients with localised prostate cancer. 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%). 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). 15727 Anthem Pkwy, Suite 600 . NOTE: Information about the cost of this plan (called the . Int J Gynaecol Obstet. This document addresses the use of maternity ultrasound in the outpatient setting. Bone Metastases. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Please enter a valid 5-digit Zip Code. 2011; 3(3):329-338. There were no new reported serious AEs. Transrectal high-intensity focused ultrasound in the treatment of localized prostate cancer: a multicenter study. Cancer. Ahhhhh! ACOG Practice Bulletin 163. Chaussy C, Thuroff S. Results and side effects of high-intensity focused ultrasound in localized prostate cancer. However, the change from baseline in MEDD intake was not statistically significant, although the authors noted a trend towards a statistically significant change. Bricker L, Medley N, Pratt JJ. Available at: Antepartum Fetal surveillance. In a prospective, non-randomized single arm trial, MRgFUS was used on 5 individuals with painful bone metastatic lesions with a pain rating of 4 or higher. 2017; 31(1):14-19. 2011; 185(4):1246-1254. The location you tried did not return a result. 2014; 106(5). Ahmed HU, Freeman A, Kirkham A, et al. Prostate Cancer Prostatic Dis. Screening for Fetal Aneuploidy. Guidelines for diagnostic imaging during pregnancy and lactation. High-intensity focused ultrasound in the treatment of primary prostate cancer: the first UK series. 2021. Due to variances in utilization patterns, each plan may choose whether to adopt a particular Clinical UM Guideline. 2008; 38(3):192-199. Schatzl G, Madersbacher S, Djavan B, et al. Bonekamp D, Wolf MB, Roethke MC, et al. You bet! Eur Urol. In the obese patient, expectations regarding visualization of fetal anatomy should be tempered. Updated Description, Discussion, References and Websites for Additional Information sections. 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. Late complications included occurrences of stenosis (9%) and fistula (0.4%). The identified primary endpoint was the improvement in self-reported pain score without an increase in pain medication utilization at 3 months. J Urol. (i.e. Updated Coding section with 10/01/2017 ICD-10-CM diagnosis code changes. High Intensity Ultrasound System For Prostate Tissue Ablation (Ablatherm). When an embryo/fetus is detected, it should be measured, and the cardiac activity should be recorded by 2-D video clip or M-mode. Pregnant Women. The authors noted that incomplete tumor ablation could be related to poor accuracy in determining the target area or movement during the procedure. 2013; 48(6):351-358. 2005; 4(3):187-192. As the bone cortex absorbs high ultrasound energy, periosteal denervation may ensue, resulting in pain relief. J Urol. Prudent use and safety diagnostic ultrasound in pregnancy. Ultrasound, the use of low-intensity sound waves to produce images, is an established diagnostic tool. Palliative treatment: Treatment given for relief of symptoms and pain rather than attempting to cure. Subtle second-trimester ultrasound markers should be interpreted in the context of a background risk based on the patients age, history, genetic screening, and serum screening results. Chin JL, Billia M, Relle J, et al. 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. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Lancet Oncol. J Urol. 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). In Ohio: Community Insurance Company. The prospective, nonrandomized, investigator-initiated, single-arm, single-center phase 1 study included 11 individuals with localized, histopathologically verified, radio-recurrent prostate cancer. 2014; 7(4):270-281. . 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. , which destroys the targeted area increase to 60-95C, which destroys the targeted tissue without damaging the tissue... Internet ] I study right to Review and update Clinical UM Guidelines periodically section to add ICD-10-CM diagnosis code.... Focal salvage therapy for localized metastatic bone pain bone pain bone pain is a common complaint for individuals metastatic! Radical prostatectomy in the United States ( MRgFUS ) ablation for the treatment localized... Rockville ( MD ): Agency for healthcare Research and Quality ( )! 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Rischmann P, Brasure M, Bardi F, Bellucci S, Rebillard X, X., expectations regarding visualization of fetal congenital anomalies in the obese patient, expectations visualization...