It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card. Accessed on October 20, 2022. Eur Urol Open Sci. Magnetic resonance imaging-guided transurethral ultrasound ablation of prostate tissue in patients with localized prostate cancer: a prospective Phase 1 clinical trial. The benefits and limitations of ultrasonography should be discussed with all patients. 2014; 7(4):270-281. Birth Defects Homepage: Diagnosis. Hemi salvage high-intensity focused ultrasound (HIFU) in unilateral radiorecurrent prostate cancer: a prospective two-centre study. Although I've had a particular monthly claim for YEARS, it doesn't always recognize the bill. Ultrasound examinations can be used to assess fetal anatomy, particularly neuroanatomy, and to monitor growth. These options carry their own risks and side effects. Transrectal high-intensity focused ultrasound: minimally invasive therapy of localized prostate cancer. Boccon-Gibod L, Djavan WB, Hammerer P, et al. Available at: Dahm P, Brasure M, Ester E, et al. 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. 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). The mean reduction in the NRS score was significant between MRgFUS and placebo (3.6 3.1 versus 0.7 2.4). 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. 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. 2015; 2015(7):CD007058. November 17, 2019. 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. Low-Intensity Pulsed Ultrasound for Fracture Nonunion. Liberman and associates (2009) used MRgFUS to treat 31 individuals with painful bone metastases who had exhausted or refused all other pain palliation methods. Principles and results of high-intensity focused ultrasound for localized prostate cancer. Whitworth M, Bricker L, Mullan C. Ultrasound for fetal assessment in early pregnancy. Participants were followed for up to 5 years post-procedure. World J Gastroenterol. Available at: Centers for Disease Control and Prevention (CDC). Grade 3 (n=1) and grade 2 (n=3) AEs related to urinary retention and urinary tract infection were reported. Statement on Biological Effects of Ultrasound in Vivo. Klotz L, Pavlovich CP, Chin J, et al. NOTE: Information about the cost of this plan (called the premium) will be . Uchida T, Tomonaga T, Kim H, et al. 2005; 4(3):187-192. PLoS One. Participants received either MRgFUS (n=112) or placebo (n=35) treatment. Palliative treatment: Treatment given for relief of symptoms and pain rather than attempting to cure. 1999b; 39(1):41-46. Available at: Centers for Medicare and Medicaid Services. Urol Oncol. Moved content of MED.00119 High Intensity Focused Ultrasound (HIFU) for Oncologic Indications to new clinical utilization management guideline document with the same title. Poggenpoel EJ, Geerts LT, Theron GB. Focal therapy for localized prostate cancer: a phase I/II trial. Yonsei Med J. Rockville (MD): Agency for Healthcare Research and Quality (US); 2020 Sep. Report No. Ideally the ultrasound is done at the same appointment as the screening mammogram. Guillaumier S, Peters M, Arya M, et al. Palermo G, Totaro A, Sacco E, et al. U.S. Food and Drug Administration (FDA). Prostate Cancer (V1.2023). J Natl Cancer Inst. Available at: Papageorghiou AT, Thilaganathan B, Bilardo CM, et al. Available at: Testing for Zika Virus Infections. In some states, insurance must cover . 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. ; AUA Prostate Cancer Clinical Guideline Update Panel. As the bone cortex absorbs high ultrasound energy, periosteal denervation may ensue, resulting in pain relief. Geiger D, Napoli A, Conchiglia A, et al. Postpartum hemorrhage. 2016; 19(3):311-316. Primary pain palliation and local tumor control in bone metastases treated with magnetic resonance-guided focused ultrasound. There were 12 grade 3 adverse events (AEs) attributable to the TULSA-PRO, all of which were resolved by 12 months. Nair SM, Hatiboglu G, Relle J, et al. 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). Int 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 . 2003; 17(8):673-677. Cochrane Database Syst Rev. Removed ICD-9 codes from Coding section. There are a number of uncontrolled case series and prospective studies which address HIFU for prostate cancer (Ahmed, 2009, 2011, 2012; Beerlage, 1999b; Blana, 2004; Chaussy, 2001; Gelet, 2000; Gelet, 2004; Guillaumier; 2018; Lawrentschuk, 2011; Muto, 2008; Napoli, 2013; Poissonnier, 2007; Shoji, 2010; Thuroff, 2003; Uchida, 2002; Uchida, 2005; Uchida, 2006a; Uchida, 2006b; Zacharakis, 2008). J Evid Based Med. Dupr A, Melodelima D, Prol D, et al. 2021. 2005; 19(6):693-701. 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. (i.e. J Urol. J Urol. In addition to treatment, these individuals should undergo a sonographic fetal evaluation to evaluate for signs of fetal or placental syphilis. High intensity focused ultrasound as first line salvage therapy in prostate cancer local relapse after radical prostatectomy: 4-year follow-up outcomes. Pregnant Women. The use of HIFU in the setting of breast cancer treatment may not allow for an adequate collection of tumor specimens to evaluate the tumor histopathology. HAIFA, Israel - MIAMI, Florida (December 22, 2022) Insightec , a global healthcare company dedicated to using acoustic energy to transform patient care, announced today that Anthem is the third national payor to cover MR-guided Focused Ultrasound for treating medication-refractory Essential Tremor. Eligibility included those at least 18 years old with at least a 3-month life expectancy with bone metastases which were painful despite previous radiation therapy (RT) but unsuitable for further RT. ACOG Practice Bulletin 163. The resulting heat and cavitation destroys the targeted tissue. American College of Radiology (ACR). BJU Int. Magnetic resonance-guided focused ultrasound for patients with painful bone metastases: phase III trial results. These options carry their own risks and side effects ( CDC ) if review is for. Unilateral radiorecurrent prostate cancer score was significant between MRgFUS and placebo ( n=35 ) treatment AEs related urinary! Prospective two-centre study Peters M, Bricker L, Djavan WB, P. A phase I/II trial attributable to the TULSA-PRO, all of which were resolved by 12.! Of prostate tissue in patients with painful bone metastases: phase III trial results T, Tomonaga T, H. 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