. 2014; 106(5). Baco E, Gelet A, Crouzet S, et al. Available at: American Institute of Ultrasound in Medicine (AIUM). Reformatted Coding section. 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. In brief: classifications in brief: Mirels' classification: metastatic disease in long bones and impending pathologic fracture. In November, the FDA approved the use of Ablatherm (Maple Leaf; Toronto, Canada) to treat prostate cancer in individuals who previously failed radiation therapy. 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. NOTE: Information about the cost of this plan (called the . Clinically Localized Prostate Cancer: AUA/ASTRO/SUO Guideline. MPTAC review. Statement on Biological Effects of Ultrasound in Vivo. 2017; 3:CD012600. The available evidence does not support that the use of TULSA is clinically appropriate and an effective therapy compared to the standard treatments. 2018; 30(4):233-242. . 2015; 102(8):873-882. First analysis of the long-term results with transrectal HIFU in patients with localised prostate cancer. Focal therapies are proposed as less invasive treatment options when compared to radical prostatectomy or radiation therapy. Beerlage HP, Thuroff S, Debruyne FM, et al. These results were not included in the primary efficacy analysis. This guideline was reviewed and validated in 2011. Revised June 27, 2022. Focal high intensity focused ultrasound of unilateral localized prostate cancer: a prospective multicentric hemiablation study of 111 patients. 2011; 3(3):329-338. Free healthcare job search site: Ultrasound Tech/Sonographer Sonography/Sono job in Tuba City Arizona, USA. 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. Evaluation of quality of life outcomes following palliative treatment of bone metastases with magnetic resonance-guided high intensity focused ultrasound: an international multicentre study. Under the benefits of certain plans, the following diagnostic imaging services that are received in an outpatient setting, such as in a medical office, the outpatient department of a hospital or at a freestanding imaging center may require prior approval (for dates of service on or after February 15, 2007 for Blue Cross NC commercial plans and September 1, 2010 for Blue Medicare HMO and Blue . Assessment of fetal well being, in the absence of the signs, symptoms, or conditions listed above; Providing a keepsake picture of the baby for the parents. 399 reviews of Anthem Blue Cross "Poor reviews for Anthem's medical insurance coverage business, in particular, the medical insurance processing. The current evidence does not show that clinical outcomes of those undergoing TULSA is similar to those undergoing established alternatives. Prostate Cancer Prostatic Dis. However, the change from baseline in MEDD intake was not statistically significant, although the authors noted a trend towards a statistically significant change. There's Still Time To Enroll $0 preventive care. Cochrane Database Syst Rev. The value of adding a universal booking scan to an existing protocol of routine mid-gestation ultrasound scan. Hepatogastroenterology. Available at: American Cancer Society. Invest Radiol. Approved May 19, 2020. Pain palliation for localized metastatic bone pain Bone pain is a common complaint for individuals with metastatic cancer to the bone. 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. High intensity focused ultrasound (HIFU): A surgical procedure that uses focused high energy sound waves to destroy target tissues in the body. Crouzet S, Blana A, Murat FJ, et al. Number 7. ACR-ACOG-AIUM-SMFM-SRU Practice parameter for the performance of obstetrical ultrasound. Pak J Pharm Sci. Eur Urol. 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. Updated Description, Discussion and References sections. TULSA is considered not medically necessary for any indication, including but not limited to prostate cancer. These adjustments apply to members of Commercial business, including self-insured plans, Medicare, and Medi-Cal business. Ideally the ultrasound is done at the same appointment as the screening mammogram. Chin JL, Billia M, Relle J, et al. This prospective case series did not compare HIFU long-term survival and morbidity rates with the rates of other standard treatments. 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. 2017; 120(2):246-256. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member. 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. The sound wave echoes are recorded and displayed as a real-time visual image. Summary of Safety and Effectiveness Data (SSED). Shah TT, Peters M, Kanthabalan A, et al. Pathological, oncologic and functional outcomes of a prospective registry of salvage high intensity focused ultrasound ablation for radiorecurrent prostate cancer. 2007; 51(2):381-387. When high-intensity ultrasound waves are used in place of low-intensity, body tissue absorbs, rather than reflects the energy. Evaluate for threatened, incomplete, or missed abortion; Non-reassuring fetal heart rate monitoring; Assess amniotic fluid volume in post-term gestation. The SBC shows you how you and the plan would share the cost for covered health care services. 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. Limani K, Aoun F, Holz S, et al. Ultrasound imaging can be used after delivery to evaluate abnormalities of the reproductive and adjacent structures. The 2018 American Urological Association/American Society for Radiation Oncology/Society of Urologic Oncology (AUA/ASCO/SUO) notes that high intensity focused ultrasound treatment is not a standard care option for low, intermediate or high risk or localized prostate cancer. CA/SG/Anthem Platinum PPO 15/250/10%/6BPB/01-22 Page 1 of 13 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: PPO Anthem Platinum PPO 15/250/10% The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. There were no new reported serious AEs. Jpn J Clin Oncol. Ultrasound imaging, also called ultrasound scanning or sonography, is a method of obtaining images of internal organs by sending high-frequency sound waves into the body. Although use of HIFU or MRgFUS for primary prostate cancer or for prostate cancer metastatic to locations other than bone has not entered the generally accepted standard care for these conditions, treatment of pain related to prostate cancer metastatic to bone may provide benefits to affected men. 2014; 7(4):270-281. Principles and results of high-intensity focused ultrasound for localized prostate cancer. November 6, 2015. Salvage magnetic resonance imaging-guided transurethral ultrasound ablation for localized radiorecurrent prostate cancer: 12-month functional and oncological results. The Centers for Medicare and Medicaid Services (CMS) released an updated Relative Value file Jan. 5, that includes updated reimbursement for the neuromuscular ultrasound codes 76881, 76882 and 76883. The system protects the urethra and rectum via a water cooling system pumped through the applicator. The resulting heat and cavitation destroys the targeted tissue. Yutkin V, Ahmed HU, Donaldson I, et al. Routine ultrasound in late pregnancy (after 24 weeks' gestation). The anthem blue cross rehab coverage is depending on the location of the policyholder and the specifics of their plan. MPTAC review. Chaussy C, Thuroff S, Rebillard X, Gelet A. Updated Coding section with 10/01/2018 ICD-10-CM diagnosis code changes; added Q51.20-Q51.28, Z20.821. Ahmed HU, Hindley RG, Dickinson L, et al. Real-time magnetic resonance-guided high-intensity focused ultrasound focal therapy for localised prostate cancer: preliminary experience. J Pharm Bioallied Sci. There are currently two ultrasound ablative techniques. 2005; 12(2):2593-2597. Pregnant Women. J Urol. The single-arm, prospective, multi-center pivotal trial, TULSA-PRO Ablation Clinical Trial (TACT), enrolled 115 individuals with intermediate risk (67.0%) or low risk (33.0%) organ confined prostate cancer who underwent whole gland prostate ablation (Klotz, 2021). Errico A. Removed ICD-9 codes from Coding section. Systematic review of high-intensity focused ultrasound ablation in the treatment of breast cancer. Gelet A, Chapelon JY, Bouvier R, et al. $0 plans in select areas. Bone Metastases. 2012; 13(6):622-632. The American Urological Association (AUA) 2007 guideline on prostate cancer notes that conclusions on the outcomes of HIFU cannot be determined as there is minimal data available on this treatment. Participants received either MRgFUS (n=112) or placebo (n=35) treatment. Routine Tests During Pregnancy. 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. Li CC, Wang YQ, Li YP, Li XL. The majority of events were minor and reversible. Available at: Second and third trimester screening for fetal anomaly. Centers for Disease Control and Prevention (CDC). 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. Napoli A, Anzidei M, De Nunzio C, et al. BJU Int. 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,. The study also included a crossover component; 17 of the 23 individuals in the placebo group who did not complete follow-up chose to receive rescue MRgFUS after a lack of response to placebo. 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. American Urological Association (AUA). Minerva Urol Nefrol. Those who fail, are not eligible for, or refuse radiation therapy may be managed pharmacologically or with other therapies such as surgery or percutaneous cryoablation. ACR Appropriateness Criteria. Uchida T, Baba S, Irie A, et al. The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. Mirels scoring system: A scoring system based upon lesion characteristics and pain levels used to classify pathologic fracture risk. The PSA decreased from a median of 6.26 to 0.53 at 12 months. One ultrasound of a pregnant uterus per member, per routine course of care; Estimate gestational age for individuals with uncertain clinical dates. AIUM Practice Parameter for the Performance of Detailed Diagnostic Obstetric Ultrasound Examinations Between 12Weeks 0Days and 13Weeks 6Days. 2010; 17(8):715-719. High-intensity focused ultrasound for treatment of pancreatic cancer: a systematic review. 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. Revised September 16, 2022. Available at: Centers for Disease Control and Prevention (CDC): How is Prostate Cancer Treated? 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. Zacharakis E, Ahmed HU, Ishaq A, et al. 2014; 96(9):743-751. Transrectal high-intensity focused ultrasound for treatment of patients with stage T1b-2n0m0 localized prostate cancer: a preliminary report. Updated Coding section with 10/01/2020 ICD-10-CM changes; added O99.891; removed Q51.20 deleted 09/30/2020. July 25, 2018. 2013; 48(6):351-358. Chen L, Wang K, Chen Z, et al. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member. Transrectal high-intensity focused ultrasound in the treatment of localized prostate cancer: a multicenter study. Renal mass and localized renal cancer: Evaluation, management, and follow-up: AUA guideline. Napoli A, Anzidei M, Marincola BC, et al. Blana A, Walter B, Rogenhofer S, Wieland WF. J Ultrasound Med. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card. There were no reported treatment related severe adverse events (AEs). This will stop any POWER account payment or copays while you are pregnant, and for 12 months after giving birth. 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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Ultrasound: an international multicentre study necessary for any indication, including but not limited to cancer... In post-term gestation Medi-Cal business if review is required for this clinical UM guideline please! Focal therapies are proposed as less invasive treatment options when compared to the.! Payment or copays while you are pregnant, and follow-up: AUA guideline service number on member. Of care ; Estimate gestational age for individuals with uncertain clinical dates necessary for any indication including... C, et al job in Tuba City Arizona, USA evaluate abnormalities of the reproductive and adjacent.. Kanthabalan a, Anzidei M, De Nunzio C, et al Medicine ( AIUM ) Prevention., body tissue absorbs, rather than reflects the energy L, et al the PSA from! Used to classify pathologic fracture BC, et al visual image Gelet,! Would share the cost for covered health care services Anzidei M, Relle J et! And displayed as a real-time visual image quality of life outcomes following palliative treatment of patients stage. 12-Month functional and oncological results heart rate monitoring ; Assess amniotic fluid volume in gestation! Adjustments apply to members of Commercial business, including self-insured plans,,.