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 for treatment of patients with stage T1b-2n0m0 localized prostate cancer: a preliminary report. FAQ 133, July 2021. Focal therapy for localized prostate cancer: a phase I/II trial. MPTAC review. This guideline was reviewed and validated in 2011. A set of individuals who were positive for insignificant disease at 12 months (n=4) or clinically significant disease at 12 months (n=5) required salvage treatment. Ultrasound is currently being used as a therapeutic treatment, for example, lithotripsy to disintegrate kidney stones. . Addition of cell-free fetal deoxyribonucleic acid (DNA) screening for aneuploidy to Medically Necessary Statement. The SBC shows you how you and the plan would share the cost for covered health care services. Boccon-Gibod L, Djavan WB, Hammerer P, et al. In addition, 21% of individuals in the MRgFUS group reduced their morphine equivalent daily dose (MEDD) intake and another 26% completely stopped their MEDD consumption. The price of a diagnostic mammogram averages from $172 under Medicare to $239 with private insurance. 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%). The mean reduction in the NRS score was significant between MRgFUS and placebo (3.6 3.1 versus 0.7 2.4). *Coverage includes fertility preservation . Focal high intensity focused ultrasound of unilateral localized prostate cancer: a prospective multicentric hemiablation study of 111 patients. BJU Int. Committee Opinion 723. This will stop any POWER account payment or copays while you are pregnant, and for 12 months after giving birth. Updated Coding section with 10/01/2016 ICD-10-CM diagnosis code changes. Updated References and Websites for additional information sections. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card. Real-time magnetic resonance-guided high-intensity focused ultrasound focal therapy for localised prostate cancer: preliminary experience. 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. Safety trial of high-intensity focused ultrasound therapy for pancreatic cancer. The available evidence does not support that the use of TULSA is clinically appropriate and an effective therapy compared to the standard treatments. Available at: Centers for Medicare and Medicaid Services. 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 . NOTE: Information about the cost of this plan (called the premium) will be . 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. The location you tried did not return a result. But in general, know that most plans cover: STD testing; Rh incompatibility testing; Prenatal vitamins; Gestational diabetes testing; Breastfeeding counseling and equipment; Post-birth birth control; Birth; Medical coverage of any complications; Dependent Care Accounts Effects of high-intensity focused ultrasound for treatment of abdominal lymph node metastasis from gastric cancer. Crouzet S, Chapelon JY, Rouvire O, et al. Rejection notice to me (if I'm lucky) and I start over. PSA nadir as a predictive factor for biochemical disease-free survival and overall survival following whole-gland salvage HIFU following radiotherapy failure. 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. 2002; 59(3):394-398. 2006b; 97(1):56-61. Eur Urol. In addition to the active and pending Medical Policies, BCBSIL has included policies which are under development or being revised. The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. 2014; 2014:186782. 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. In the 25 participants that were able to tolerate a complete treatment, 72% (18/25) reported significant pain reduction of at least 2 points on the VAS scale, 24% (6/25) reported no reduction in pain and 4% (1/25) reported an increase in pain levels. 2012; 118(12):3071-3078. Cochrane Database Syst Rev. J Pharm Bioallied Sci. You can choose your preferred appointment time on our website, www.ultrasound-first.com, or you can call Lexie at the office (314-782-2034) if you need help or have any questions. Prostate cancer therapy with high-intensity focused ultrasound. Kanthabalan A, Peters M, Van Vulpen M, et al. 2021; 127(5):544-552. HIFU or MRgFUS has also been studied as a potential treatment of various cancers. Rischmann P, Gelet A, Riche B, et al. 2015; 2015(7):CD007058. Improved outcomes with advancements in high intensity focused ultrasound devices for the treatment of localized prostate cancer. Urology. Eur Urol. Ultrasound examinations can be used to assess fetal anatomy, particularly neuroanatomy, and to monitor growth. Cochrane Database Syst Rev. Bone Metastases. Medicare Supplement Plan F is great because it provides the most coverage of the 10 currently available MedSup plans. 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. 2004; 58(4):382-390. October 2016. 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. Available at: High Intensity Ultrasound System For Prostate Tissue Ablation (Focal One). $15 UK HEALTHCARE PRIMARY CARE CO-PAY $25 ANTHEM PRIMARY CARE CO-PAY $40 Approximately 30% of all individuals with cancer develop metastatic bone lesions and 50-75% of these individuals report significant pain. Re: Salvage high-intensity focused ultrasound for patients with recurrent prostate cancer after brachytherapy. These adjustments apply to members of Commercial business, including self-insured plans, Medicare, and Medi-Cal business. Int J Gynaecol Obstet. 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). Updated June 13, 2019. Rebillard X, Gelet A, Davin JL, et al. HIP Maternity will cover enhanced benefits . Adverse events included grade 1 or 2 hematuria, urinary tract infections or acute urinary retention, and grade 3 epididymitis. Bone metastases are common in breast and prostate cancer (Liberman, 2009). Limani K, Aoun F, Holz S, et al. 2015 Mar;34(3):435-440. Salvage high-intensity focused ultrasound for patients with recurrent prostate cancer after brachytherapy. 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.. While some trials using HIFU to treat pancreatic or liver cancer have shown some promising results, these trials have lacked a comparator group (Chen, 2015; Dupr, 2015; Shi, 2015; Sofuni, 2014). Elterman D, Li W, Hatiboglu G, et al. The document header wording updated from Current Effective Date to Publish Date. Updated Discussion/General Information, References and Websites for Additional Information sections. Step 1: Report your pregnancy to your health plan. Prostate cancer is the most commonly diagnosed cancer in men, accounting for 19% of all new cancer cases. American Urological Association (AUA). Chaussy C, Thuroff S. The status of high-intensity focused ultrasound in the treatment of localized prostate cancer and the impact of a combined resection. Find top doctors who perform Rectal Ultrasound near you in Anthem, AZ. There are currently more than 125 Treatment Centers around the world using Insightec's Exablate Neuro platform to treat Essential Tremor. 2016; 47(4):530-532. Urology. MPTAC review. 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. The maternal cervix and adnexa should be examined. 2017; 197(1):97-102. Blana A, Walter B, Rogenhofer S, Wieland WF. The uterus, cervix, adnexa, and cul-de-sac region should be examined. An mpMRI, a transrectal ultrasound guided biopsy and a cystoscopy were performed at 12 months post-procedure. Ultrasound, the use of low-intensity sound waves to produce images, is an established diagnostic tool. Update date: March 4, 2022. Eur Urology. Poggenpoel EJ, Geerts LT, Theron GB. 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. High Intensity Ultrasound System For Prostate Tissue Ablation (Ablatherm). 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 . Blana A, Murat FJ, Walter B, 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. This early study focused on safety and technical feasibility rather than clinical outcomes. Medical Policy & Technology Assessment Committee (MPTAC) review. 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. 2015; 2015(6):CD001451. The study has several methodological flaws, including lack of a comparison group, and uncertainty regarding the percentage of subjects who completed the follow-up period. 2008; 38(3):192-199. 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. Ultrasound Tech in San Antonio, Texas, United States. 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. 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. Pak J Pharm Sci. BJU Int. Hoosier Healthwise. ISUOG Interim Guidance on ultrasound for Zika virus infection in pregnancy: information for healthcare professionals. ACR Appropriateness Criteria. You should contact Anthem Blue Cross and Blue Shield directly to appeal denial of coverage for medical claims by calling 1855- -641-4862. Updated Coding section to include ICD-10-CM diagnosis codes Z36.0-Z36.9. Approved August 19, 2021. Government Agency, Medical Society, and Other Authoritative Publications: Maternal UltrasoundObstetricPrenatalSonography. 2021; 35(4):497-505. Reaffirmed 2021. MedlinePlus. Researchers used the visual analog pain score (VAS) to measure pain levels. Available at: U.S. National Library of Medicine. 2018; 51(4):463-469. Influence of high intensity focused ultrasound (HIFU) treatment to the pancreatic function in pancreatic cancer patients. Available at: Centers for Disease Control and Prevention (CDC): How is Prostate Cancer Treated? See the following related document for HIFU treatment non-oncologic indications: For information regarding other palliative treatments of metastatic bone lesions, please see the following: Metastatic lesions located 1 centimeter (cm) or greater from skin and major nerve bundles; Individual does not present an increased risk of fracture from the procedure (for example, a score of 7 or less on Mirels fracture risk score); Individual does not require surgical stabilization or have clinically significant comorbidities; Individual is not a candidate for other therapies as evidenced by pain refractory to previous radiation therapy. Jawad MU, Scully SP. Reaffirmed October 2021. Klotz L, Pavlovich CP, Chin J, et al. Bonekamp and associates (2019) performed a quantitative analysis of viable prostate tissue volume reduction at 12 months post-procedure. 2000; 37(6):695-701. Focal salvage high-intensity focused ultrasound in radiorecurrent prostate cancer. Hinyokika Kiyo. . NCD #220.5. Pain palliation in patients with bone metastases using MR-guided focused ultrasound surgery: a multicenter study. J Urol. Updated References section. Clin Orthop Relat Res. Individuals received either whole gland (n=8) or partial (n=8) ablation. Previously, this recommendation was graded as a 2A. 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. After excluding the drop-out groups the results remained similarly statistically significant. 2017; 31(1):14-19. The updated file enables providers to separately bill for the professional component (26) and the technical component (TC). Ideally the ultrasound is done at the same appointment as the screening mammogram. Medicare and Medicaid services M, et al focal therapy for localised prostate cancer: experience! 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