2005; 2(4):191-198. Nat Clin Pract Urol. Beerlage HP, Thuroff S, Debruyne FM, et al. 2017; 197(1):97-102. In Ohio: Community Insurance Company. Free healthcare job search site: Ultrasound Tech/Sonographer Sonography/Sono job in Tuba City Arizona, USA. Participants included those who could not undergo or refused all other available options for pain palliation. When high-intensity ultrasound waves are used in place of low-intensity, body tissue absorbs, rather than reflects the energy. 2015 Mar;34(3):435-440. Radiother Oncol. BJU Int. Br J Surg. August 15, 2019. 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. Ultrasound imaging can be used after delivery to evaluate abnormalities of the reproductive and adjacent structures. Lawrentschuk N, Finelli A, Van der Kwast TH, et al. Early prospective studies evaluating MRgFUS reported promising results. Prostate cancer is the second leading cause of death with approximately 39,430 deaths in 2018 (Bekelman, 2018). Transrectal high-intensity focused ultrasound: minimally invasive therapy of localized prostate cancer. Jpn J Clin Oncol. Poggenpoel EJ, Geerts LT, Theron GB. The identified primary endpoint was the improvement in self-reported pain score without an increase in pain medication utilization at 3 months. 2014; 7(4):270-281. Addition of cell-free fetal deoxyribonucleic acid (DNA) screening for aneuploidy to Medically Necessary Statement. Routine Tests During Pregnancy. 2018. Available at. This study was a retrospective case series involving 804 subjects who underwent HIFU and were included in an industry-sponsored registry. Accessed on September 13, 2022. After excluding the drop-out groups the results remained similarly statistically significant. Int J Gynaecol Obstet. There were no new reported serious AEs. 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. 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. 2018; 74(4):422-429. Clin Oncol (R Coll Radiol). check_circle Item Saved! The authors noted that incomplete tumor ablation could be related to poor accuracy in determining the target area or movement during the procedure. Alldred SK, Takwoingi Y, Guo B, et al. An mpMRI, a transrectal ultrasound guided biopsy and a cystoscopy were performed at 12 months post-procedure. Updated Coding section with 10/01/2017 ICD-10-CM diagnosis code changes. MRI-TULSA resulted in an 88% reduction of viable prostate tissue volume. Revised June 27, 2022. 2021; 127(5):544-552. 2013; 63(2):395-398. 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%). Relief of lower urinary tract symptoms after MRI-guided transurethral ultrasound ablation for localized prostate cancer: subgroup analyses in patients with concurrent cancer and benign prostatic hyperplasia. Thuroff S, Chaussy C. High-intensity focused ultrasound: complications and adverse events. Focal salvage high-intensity focused ultrasound in radiorecurrent prostate cancer. Hematology/Oncology Subcommittee review. Available at: Centers for Disease Control and Prevention (CDC). AIUM practice guideline for the performance of obstetric ultrasound examinations. 2013; 48(6):351-358. 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,. Reaffirmed 2021. Results indicated that median survival in RFA, IRE and SBRT was more favorable compared to HIFU. The PSA level, which had dropped following treatment, remained low. In an intent-to-treat analysis, 63% (72/115) were reported to have a complete histological response and had no evidence of cancer. This prospective case series did not compare HIFU long-term survival and morbidity rates with the rates of other standard treatments. J Endourol. Indiana Medicaid for Members. Joo B, Park MS, Lee SH, et al. * Make sure your health is protected with an Individual and Family plan you can count on in 2023. Step 2: After you become pregnant, you will join HIP Maternity. The maternal cervix and adnexa should be examined. Researchers used the visual analog pain score (VAS) to measure pain levels. 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. Added medically necessary indication when there is a known or suspected exposure to the Zika virus to the Clinical Indications section. A multicentre study of 5-year outcomes following focal therapy in treating clinically significant nonmetastatic prostate cancer. They determined that Cloyd had ovarian cysts, not appendicitis. Palermo G, Totaro A, Sacco E, et al. BJU Int. 2014; 11(6):303. 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. 2008; 38(3):192-199. Single high intensity focused ultrasound session as a whole gland primary treatment for clinically localized prostate cancer: 10-year outcomes. 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. Effects of high-intensity focused ultrasound for treatment of abdominal lymph node metastasis from gastric cancer. At 2 weeks follow-up, all individuals experienced a decrease in VAS pain scores from baseline (1.5-5). 2016; 70(3):447-455. Lumiani A, Samun D, Sroka R, Muschter R. Single center retrospective analysis of fifty-two prostate cancer patients with customized MR-guided transurethral ultrasound ablation (TULSA). Statement on Biological Effects of Ultrasound in Vivo. These studies have a number of methodological limitations, including a lack of randomization of participants, a lack of a comparator group and limited follow-up for oncologic outcomes. 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. 2001; 15(4):437-440. Minerva Urol Nefrol. Guidelines for diagnostic imaging during pregnancy and lactation. 2004; 58(4):382-390. There was 1 in-field and 2 out-of-field recurrences reported at that time. 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. The system protects the urethra and rectum via a water cooling system pumped through the applicator. The PSA decreased from a median of 6.26 to 0.53 at 12 months. Federal and State law, as well as contract language, and Medical Policy take precedence over Clinical UM Guidelines. Focal therapy with high-intensity-focused ultrasound in the treatment of localized prostate cancer. Magnetic resonance-guided focused ultrasound for patients with painful bone metastases: phase III trial results. Nair SM, Hatiboglu G, Relle J, et al. The majority of attributable AEs were grade 1 or 2. September 15, 2017. Committee Opinion 723. 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). Available at: Dahm P, Brasure M, Ester E, 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. Ultrasound examinations, particularly if obtained soon after onset of infection, may not identify prenatal features of congenital Zika syndrome and structural manifestations can be identified at later points in pregnancy. The benefits and limitations of ultrasonography should be discussed with all patients. Number 7. NCD #220.5. Hepatogastroenterology. 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. Schatzl G, Madersbacher S, Djavan B, et al. 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. The authors theorized that the high rate of salvage treatment at 3 years follow-up could be attributed to suboptimal staging and treatment. PSA nadir as a predictive factor for biochemical disease-free survival and overall survival following whole-gland salvage HIFU following radiotherapy failure. Available at: Second and third trimester screening for fetal anomaly. The clearance was based upon the Ablatherm device as the predicate device. Participants were followed for up to 5 years post-procedure. Bone pain is a common complaint for individuals with metastatic cancer to the bone. Peek and associates (2015) conducted a systematic review of the use of HIFU in breast cancer. Approved May 19, 2020. Chen L, Wang K, Chen Z, et al. 2017; 3:CD012600. First clinical experience of intra-operative high intensity focused ultrasound in patients with colorectal liver metastases: a phase I-IIa study. Placenta Accreta Spectrum. Cochrane Database Syst Rev. 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). 2015; 194(1):114. J Endourol. Ultrasound in pregnancy. Grade 3 (n=1) and grade 2 (n=3) AEs related to urinary retention and urinary tract infection were reported. The resulting heat and cavitation destroys the targeted tissue. Boccon-Gibod L, Djavan WB, Hammerer P, et al. Anthem has begun denying coverage for . Adult Cancer Pain (V2.2022). 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. 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 baseline median PSA of 7.6 ng/ml decreased to 0.23 ng/ml at 12 months follow-up. Salvage high-intensity focused ultrasound (HIFU) for locally recurrent prostate cancer after failed radiation therapy: Multi-institutional analysis of 418 patients. 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. October 2016. J Endourol. 2000; 14(6):519-528. Cancer. Evaluation of quality of life outcomes following palliative treatment of bone metastases with magnetic resonance-guided high intensity focused ultrasound: an international multicentre study. 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. Five years experience of transrectal high-intensity focused ultrasound using the Sonablate device in the treatment of localized prostate cancer. TULSA is considered not medically necessary for any indication, including but not limited to prostate cancer. 2012; 13(6):622-632. Twelve-month prostate volume reduction after MRI-guided transurethral ultrasound ablation of the prostate. In those individuals who reported a decrease in pain levels, 50% (9/18) reported complete relief of pain, with 52% reporting significant pain relief beginning 3 days post treatment. Approximately 30% of all individuals with cancer develop metastatic bone lesions and 50-75% of these individuals report significant pain. MPTAC review. This study was defined by the regulatory agency to evaluate the effectiveness of the device to ablate prostate tissue. 2017; 31(1):14-19. Previously, CDC recommended serial ultrasounds every 3-4 weeks for women with laboratory evidence of Zika virus infection based on existing fetal growth monitoring for other maternal conditions (e.g., hypertension or diabetes). ACOG Practice Bulletin Number 171. Zika virus was first reported in South America in May 2015 and since that time has now appeared in the United States. 2004; 63(4):625-629. 2018; 6:8. Safety trial of high-intensity focused ultrasound therapy for pancreatic cancer. Medical Policy & Technology Assessment Committee (MPTAC) review. MPTAC review. Updated Description, Coding, Discussion and References sections. The feasibility and safety of high-intensity focused ultrasound as salvage therapy for recurrent prostate cancer following external beam radiotherapy. (2018). This document addresses the use of maternity ultrasound in the outpatient setting. 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). Management of preterm labor. A complete retroperitoneal US study visualizes all the structures or organs within the anatomic description of that study. Lancet Oncol. Retroperitoneal ultrasound (US) studies represent the ultrasonic imaging of retroperitoneal organs for the diagnosis and management of abnormalities that occur within the retroperitoneum. HIFU has been proposed as a treatment for multiple oncologic conditions. Napoli A, Anzidei M, De Nunzio C, et al. In some states, insurance must cover . Crouzet S, Murat FJ, Pommier P, et al. J Urol. 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 . The routine use of pulsed Doppler ultrasound to either document or listen to embryonic/fetal cardiac activity is discouraged. Shoji S, Nakano M, Nagata Y, et al. The sound wave echoes are recorded and displayed as a real-time visual image. Federal and State law, as well as contract language, and Medical Policy take precedence over Clinical UM Guidelines. Updated Description, Discussion, References and Websites for Additional Information sections. BJU Int. Rockville (MD): Agency for Healthcare Research and Quality (US); 2020 Sep. Report No. J Urol. The value of adding a universal booking scan to an existing protocol of routine mid-gestation ultrasound scan. Hurwitz MD, Ghanouni P, Kanaev SV, et al. Peek MC, Ahmed M, Napoli A, et al. Prostate. At 12 months, the majority of participants (10/11) were cancer free in the ablated area and maintained a low stable PSA. The uterus, cervix, adnexa, and cul-de-sac region should be examined. Before you decide to pass on Plan F, though, do your due diligence and see how much the insurance . Ultrasound is currently being used as a therapeutic treatment, for example, lithotripsy to disintegrate kidney stones. Therapies for clinically localized prostate cancer [Internet]. Real-time magnetic resonance-guided high-intensity focused ultrasound focal therapy for localised prostate cancer: preliminary experience. 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. The wait is over. Low-Intensity Pulsed Ultrasound for Fracture Nonunion. . A complete resolution of pain at 1 year follow-up was shown in 2 participants (Joo, 2015). However, the change from baseline in MEDD intake was not statistically significant, although the authors noted a trend towards a statistically significant change. Added not medically necessary statement for TULSA. 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. Ultrasound averages range from $54 to $100. Available at: Papageorghiou AT, Thilaganathan B, Bilardo CM, et al. Although the exact mechanism of analgesic action of MRgFUS in pain palliation is unknown, studies have pointed to a few explanations. 2017; 69(1):93-100. MPTAC review. 2014; 114(4):532-540. Eur Urol. Added Websites for Additional Information section. Ahmed HU, Freeman A, Kirkham A, et al. Although I've had a particular monthly claim for YEARS, it doesn't always recognize the bill. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card. 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. Blana A, Walter B, Rogenhofer S, Wieland WF. Available at: Magnetic Resonance guided Focused Ultrasound Surgery System (MRgFUS) ExAblate Model 2000/2100. 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