Cochrane Database Syst Rev. First analysis of the long-term results with transrectal HIFU in patients with localised prostate cancer. 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. 510K Premarket notification. Contact us today for information about Anthem or for questions regarding Medicaid programs and coverage. Insurance coverage for whole-breast ultrasound is evolving. The use of high intensity focused ultrasound (HIFU) is considered medically necessary for pain palliation in individuals with localized metastatic bone pain when all the following criteria are met: High intensity focused ultrasound (HIFU) is considered not medically necessary when the above criteria are not met and for all other indications, including but not limited to, the treatment of prostate cancer. 2015; 62(137):140-143. ACR Appropriateness Criteria. Colombel M, Gelet A. Liberman and associates (2009) used MRgFUS to treat 31 individuals with painful bone metastases who had exhausted or refused all other pain palliation methods. Urology. HIFU or MRgFUS has also been studied as a potential treatment of various cancers. Reaffirmed October 2021. Early prospective studies evaluating MRgFUS reported promising results. Available at: U.S. National Library of Medicine. Ahhhhh! Updated Coding section with 10/01/2018 ICD-10-CM diagnosis code changes; added Q51.20-Q51.28, Z20.821. In addition to the active and pending Medical Policies, BCBSIL has included policies which are under development or being revised. Zhang M, Liu L, Wang J, et al. Available at: Centers for Disease Control and Prevention (CDC). You bet! Visit our official site today for more details. 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. 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,. 2004; 7(4):289-294. Invest Radiol. 2012; 118(17):4148-4155. 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. In a statement, Anthem says, "Anthem health plans cover 222 contraceptive products at $0 cost share on our ACA Preventive List." The company went on to say that it covers "at least one product" in . Postpartum hemorrhage. Participants were followed for up to 5 years post-procedure. Revised June 27, 2022. 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. Gardner TA, Koch MO. 2017; 31(1):14-19. 2001; 15(4):437-440. In Ohio: Community Insurance Company. Guillaumier S, Peters M, Arya M, et al. 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. Pregnant Women. The doctors in the emergency room did multiple tests including a CT scan and ultrasound. Pak J Pharm Sci. J Urol. Updated June 13, 2019. Dupr A, Melodelima D, Prol D, et al. Updated Coding section with additional diagnosis codes D25.0-D25.9, O26.872-O26.879, O99.210-O99.213, O99.810. In the case of monochorionic twins, one scan per two weeks in the third trimester is considered medically necessary; For twin-twin transfusion syndrome, one scan per week and serial exams, more than once per week, beginning once the diagnosis of monochorionic twins or twin-twin transfusion is made; Confirm suspected abnormal fetal position or presentation; As an adjunct to external version from breech to vertex presentation; A known or suspected exposure to Zika virus. Mol Urol. Management of preterm labor. AIUM Practice Parameter for the Performance of Detailed Diagnostic Obstetric Ultrasound Examinations Between 12Weeks 0Days and 13Weeks 6Days. J Urol. In a systematic review, Li and colleagues (2014) performed a meta-analysis on the use of HIFU in combination with radiotherapy or chemotherapy in the treatment of pancreatic cancer. Thuroff S, Chaussy C. High-intensity focused ultrasound: complications and adverse events. 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. 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. CPT codes Dx codes 76801 76802 D25, D25.0, D25.1, D25.2, D25.9, O0900, O0901, O0902, O0903, O09511, O09512, Available at: Papageorghiou AT, Thilaganathan B, Bilardo CM, et al. 2014; 114(4):532-540. (i.e. The recommendations are based on limited data. The available evidence does not support that the use of TULSA is clinically appropriate and an effective therapy compared to the standard treatments. Principles and results of high-intensity focused ultrasound for localized prostate cancer. 2018; 6:8. 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. 2015; 10(2):e0118212. Federal and State law, as well as contract language, and Medical Policy take precedence over Clinical UM Guidelines. In the absence of specific indications, the optimal time for a single ultrasound examination is at 1822 weeks of gestation. 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 . However, the change from baseline in MEDD intake was not statistically significant, although the authors noted a trend towards a statistically significant change. Uchida T, Sanghvi NT, Gardner TA, et al. Gelet A, Chapelon JY, Bouvier R, et al. The SBC shows you how you and the plan would share the cost for covered health care services. Peek and associates (2015) conducted a systematic review of the use of HIFU in breast cancer. American Urological Association (AUA). Required ultrasound or colonoscopy for select adult patients based on clinical scenario; Ultrasound-first approach for pediatric abdominal and pelvic pain . Ahmed HU, Hindley RG, Dickinson L, et al. J Ther Ultrasound. Pickles T, Goldenberg L, Steinhoff G. Technology review: high-intensity focused ultrasound for prostate cancer. The five HIFU trials included a total of only 136 individuals. Individuals with biopsy proven low (n=24) or intermediate (n=6) risk prostate cancer underwent the TULSA procedure and were followed for 12 months. Prostate Cancer Prostatic Dis. 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.. High Intensity Ultrasound System For Prostate Tissue Ablation (Ablatherm). 2018; 74(4):422-429. . J Urol. Kanthabalan A, Peters M, Van Vulpen M, et al. August 27, 2020. 2010; 468(10):2825-2827. 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. Updated Coding section with 10/01/2022 ICD-10-CM changes; added O35.00X0-O35.9XX9 replacing O35.0XX0-O35.9XX9. TULSA is considered not medically necessary for any indication, including but not limited to prostate cancer. While the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines (CPG) in Oncology for Adult Cancer Pain (V2.2022) document notes that the palliative effects of HIFU have been demonstrated in several small studies, no recommendation for or against the use of HIFU for pain palliation was given. Comprehensive medical coverage that covers many common services at no cost or for a low copay. Jpn J Clin Oncol. 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. 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. Available at: U.S. National Library of Medicine. Focused ultrasound for the treatment of bone metastases: effectiveness and feasibility. While there is no reliable evidence to support ultrasounds performed during pregnancy will harm a fetus, there is general agreement that the casual use of ultrasonography during pregnancy should be avoided (ACOG, 2018). Effectiveness of 12-13-week scan for early diagnosis of fetal congenital anomalies in the cell-free DNA era. Approved May 19, 2020. Eur Urol. Li CC, Wang YQ, Li YP, Li XL. 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. . October 2016. Centers for Disease Control and Prevention (CDC). 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. MPTAC review. Albisinni S, Aoun F, Bellucci S, et al. Updated Coding section; added ICD-10-CM code ranges O98.111-O98.119, O99.310-O99.313, O99.320-O99.323, O99.330-O99.333. There were no reported treatment related severe adverse events (AEs). ACOG Practice Bulletin Number 183, October 2017. Can J Urol. The identified primary endpoint was the improvement in self-reported pain score without an increase in pain medication utilization at 3 months. 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). 2016; 70(3):447-455. August 15, 2019. This guideline was reviewed and validated in 2011. ; AUA Prostate Cancer Clinical Guideline Update Panel. (2018). Eur Urol. High-intensity focused ultrasound for treatment of pancreatic cancer: a systematic review. 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. Chen L, Wang K, Chen Z, et al. 2021; 127(5):544-552. Br J Surg. Updated References. Chin JL, Billia M, Relle J, et al. Systematic review of high-intensity focused ultrasound ablation in the treatment of breast cancer. Revised May 20, 2020. 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. First clinical experience of intra-operative high intensity focused ultrasound in patients with colorectal liver metastases: a phase I-IIa study. 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. 2014; 84(5):1157-1162. Updated References and Websites for additional information sections. This early study focused on safety and technical feasibility rather than clinical outcomes. 2012; 116(3):201-205. 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. J Endourol. Control of prostate cancer by transrectal HIFU in 227 patients. MPTAC review. Prostate Cancer (V1.2023). Ganzer R, Robertson CN, Ward JF, et al. At 3 months, 72.2% (13/18) reported no pain without the use of pain medication, and 16.7% (3/18) reported a drop of at least 2 points on pain scale without an increase in pain medication.
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