HIFU is a non-invasive ablative procedure which has the advantage of sparing surrounding tissue which may reduce postoperative morbidity and hasten recovery. Real-time magnetic resonance-guided high-intensity focused ultrasound focal therapy for localised prostate cancer: preliminary experience. MPTAC review. High intensity focused ultrasound (HIFU): A surgical procedure that uses focused high energy sound waves to destroy target tissues in the body. Committee Opinion 723. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card. Book an appointment today! Approximately 98% of subjects received 1 (60%) or 2 treatments (38%). J Ultrasound Med. 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 . Quality of life following high-intensity focused ultrasound for the treatment of localized prostate cancer: a prospective study. MPTAC review. Before you decide to pass on Plan F, though, do your due diligence and see how much the insurance . 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. 2012; 116(3):201-205. Magnetic resonance imaging-guided transurethral ultrasound ablation of prostate cancer. 2000; 14(6):519-528. The remaining 11.1% (2/18) reported pain reoccurrence which required pharmacological care. This study was a retrospective case series involving 804 subjects who underwent HIFU and were included in an industry-sponsored registry. Ahmed HU, Hindley RG, Dickinson L, et al. When services are Not Medically Necessary:For the procedure and diagnosis codes listed above when criteria are not met. Search doctors, conditions, or procedures . The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. 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). Approximately 30% of all individuals with cancer develop metastatic bone lesions and 50-75% of these individuals report significant pain. The updated file enables providers to separately bill for the professional component (26) and the technical component (TC). In addition, there are limitations on tissue tolerance at sites previously irradiated. Int J Gynaecol Obstet. 2015; 193(1):103-110. Updated References. Zip Code or City, State . MPTAC review. MPTAC review. Baco E, Gelet A, Crouzet S, et al. Evaluate for threatened, incomplete, or missed abortion; Non-reassuring fetal heart rate monitoring; Assess amniotic fluid volume in post-term gestation. Effectiveness of 12-13-week scan for early diagnosis of fetal congenital anomalies in the cell-free DNA era. CT, digital radiography, ultrasound, mammography and DEXA equipment at each of our outpatient centers. Alldred SK, Takwoingi Y, Guo B, et al. Available at: American Institute of Ultrasound in Medicine (AIUM). Statement on Biological Effects of Ultrasound in Vivo. Pregnant Women. The primary endpoint was the proportion of individuals who achieved a 75% or greater reduction in PSA at 12 months post-procedure. Eur Urol. The routine use of pulsed Doppler ultrasound to either document or listen to embryonic/fetal cardiac activity is discouraged. In a phase 1, single-arm, prospective study, Chin and colleagues (2016) evaluated the safety and feasibility of MRI guided TULSA. Screening for Fetal Aneuploidy. Zhang M, Liu L, Wang J, et al. Find a doctor near you. 2002; 59(3):394-398. Klotz L, Pavlovich CP, Chin J, et al. U.S. Food and Drug Administration (FDA). Reaffirmed 2018. In 2016, ACOG and the SMFM released a practice advisory regarding the current information and recommendations regarding the Zika virus. Updated Coding section with 10/01/2017 ICD-10-CM diagnosis code changes. 2015; 2015(6):CD001451. Providers are responsible for billing the appropriate CPT code, modifier, and diagnosis combinations. Insurance coverage for whole-breast ultrasound is evolving. Updated Coding, Description, Discussion/General Information, and References. Local recurrence of prostate cancer after external beam radiotherapy: early experience of salvage therapy using high-intensity focused ultrasonography. Reformatted Coding section. In November, the FDA approved the use of Ablatherm (Maple Leaf; Toronto, Canada) to treat prostate cancer in individuals who previously failed radiation therapy. AIUM practice guideline for the performance of obstetric ultrasound examinations. Eur Urol Open Sci. 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). Clin Orthop Relat Res. The PSA decreased from a median of 6.26 to 0.53 at 12 months. The TULSA-PRO (Profound Medical Corp., Fort Myers, FL) received 510(k) clearance by the FDA in 2019. Participants included those who could not undergo or refused all other available options for pain palliation. Whole-gland salvage high-intensity focused ultrasound therapy for localized prostate cancer recurrence after external beam radiation therapy. 2015; 102(3):182-193. The American College of Obstetricians and Gynecologists (ACOG) 2018 Practice Bulletin Ultrasound in Pregnancy lists the following recommendations: The following conclusions are based on good and consistent evidence (Level A): The following conclusions are based on limited or inconsistent evidence (Level B): The following conclusion and recommendation are based primarily on consensus and expert opinion (Level C): The American College of Radiology (ACR), the American Institute of Ultrasound in Medicine (AIUM), ACOG, the Society for Maternal Fetal Medicine (SMFM), and the Society of Radiologists in Ultrasound (SRU) practice parameter (2018) notes: A standard obstetrical ultrasound examination in the first trimester includes evaluation of the presence, size, location, and number of gestational sac(s). However, residual tumors of less than 10% were found in 29.4% of cases and residual tumors between 10-90% were found in 22.7% of cases. If maternal testing does not suggest infection, patients should receive the same ultrasound screening as any other pregnant woman as part of standard routine prenatal care. This document addresses the use of maternity ultrasound in the outpatient setting. New 2020. A clinically significant biopsy was reported in 34% (10/29) of participants with 59% (17/29) of participants reporting any positive biopsy. Ultrasound imaging can be used after delivery to evaluate abnormalities of the reproductive and adjacent structures. Boccon-Gibod L, Djavan WB, Hammerer P, et al. Review January 10, 2022. Medical Policy & Technology Assessment Committee (MPTAC) review. 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 recommendations are based on limited data. Five years experience of transrectal high-intensity focused ultrasound using the Sonablate device in the treatment of localized prostate cancer. 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. As the bone cortex absorbs high ultrasound energy, periosteal denervation may ensue, resulting in pain relief. The difference in response rates between MRgFUS and placebo at 3 months was significant (64.3% versus 20.0%). A complete retroperitoneal US study visualizes all the structures or organs within the anatomic description of that study. 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 2000; 37(6):695-701. AIUM Practice Parameter for the Performance of Limited Obstetric Ultrasound Examinations by Advanced Clinical Providers. 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. 2015 Mar;34(3):435-440. Sonablate was classified as a class II device. HIFU therapy was included in a comparative effectiveness review of clinically localized prostate cancer treatments (Dahm, 2020). For other common visits, this is what you'll pay with PPO. High-intensity focused ultrasound in the treatment of primary prostate cancer: the first UK series. For instance, if you want to take advantage of inversion therapy, massage, ultrasound therapy, or computer-assisted adjustments, youll need to ask your insurance company about the availability of coverage for these things . Updated Coding section; corrected ICD-10 diagnosis code O41.00X0. Prostate cancer is the most commonly diagnosed cancer in men, accounting for 19% of all new cancer cases. J Urol. In February 2000, the labeled indication for the SAFHS (now known as the Exogen device) (Smith and Nephew, Inc., Biologics & Spine, Durham, NC) was expanded to include the treatment of established fracture nonunions, excluding the skull and vertebra. NOTE: Information about the cost of this plan (called the . 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. For any of the diagnosis codes listed below for abnormalities and high-risk conditions, and including the following: Encounter for supervision of normal pregnancy [codes 76801, 76805, when criteria are met], Encounter for antenatal screening of mother, When services may be Medically Necessary when criteria are met for known or suspected abnormality of maternal reproductive structure, fetus, or placenta, or fetal viability or other high-risk conditions:For the procedure codes listed above for the following diagnoses, Incomplete spontaneous abortion without complication, Complete or unspecified spontaneous abortion without complication, Failed attempted termination of pregnancy without complication, Supervision of pregnancy with history of infertility, Supervision of pregnancy with history of ectopic pregnancy, Supervision of pregnancy with history of molar pregnancy, Supervision of pregnancy with history of pre-term labor, Supervision of pregnancy with other poor reproductive or obstetric history, Supervision of pregnancy with insufficient antenatal care, Supervision of elderly primigravida and multigravida, Supervision of other or unspecified high risk pregnancy, Pre-existing essential hypertension complicating pregnancy, Pre-existing hypertensive heart disease complicating pregnancy, Pre-existing hypertensive chronic kidney disease complicating pregnancy, Pre-existing hypertensive heart and chronic kidney disease complicating pregnancy, Pre-existing secondary hypertension complicating pregnancy, Unspecified pre-existing hypertension complicating pregnancy, Pre-existing hypertension with pre-eclampsia; first, second or third trimester, Pre-existing hypertension with pre-eclampsia; unspecified trimester, Mild to moderate pre-eclampsia; unspecified, second or third trimester, Severe pre-eclampsia; unspecified, second or third trimester, HELLP syndrome; unspecified, second or third trimester, Unspecified pre-eclampsia; unspecified, second or third trimester, Unspecified maternal hypertension; first, second or third trimester, Unspecified maternal hypertension; unspecified trimester, Pre-existing diabetes mellitus, type 1, in pregnancy, Pre-existing diabetes mellitus, type 2, in pregnancy, Unspecified pre-existing diabetes mellitus in pregnancy, Gestational diabetes mellitus in pregnancy, Other pre-existing diabetes mellitus in pregnancy, Unspecified diabetes mellitus in pregnancy, Pregnancy care for patient with recurrent pregnancy loss, Retained intrauterine contraceptive device in pregnancy, Uterine size-date discrepancy complicating pregnancy, Complications specific to multiple gestation, Maternal care for malpresentation of fetus, Maternal care for abnormality of pelvic organs, Maternal care for known or suspected fetal abnormality and damage, Maternal care for known or suspected poor fetal growth, Maternal care for viable fetus in abdominal pregnancy, Pregnancy with inconclusive fetal viability, Maternal care for abnormalities of the fetal heart rate or rhythm, Maternal care for other specified fetal problems, Maternal care for fetal problem, unspecified, Other disorders of amniotic fluid and membranes, Fetus-to-fetus placental transfusion syndrome, Morbidly adherent placenta, other/unspecified placental disorder, Premature separation of placenta (abruptio placentae), Retained placenta and membranes, without hemorrhage, Abnormality in fetal heart rate and rhythm complicating labor and delivery, Other specified diseases and conditions complicating pregnancy, Contact with and (suspected) exposure to Zika virus. 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