Temperatures within the targeted area increase to 60-95C, which destroys the targeted tissue without damaging the adjacent tissue. Primary pain palliation and local tumor control in bone metastases treated with magnetic resonance-guided focused ultrasound. 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 treatment group reported an AE frequency of 76.2% versus 23.8% in the sham group. Updated Coding section with 10/01/2018 ICD-10-CM diagnosis code changes; added Q51.20-Q51.28, Z20.821. The current evidence is insufficient to support the use of HIFU as a generally accepted oncological treatment. Retroperitoneal ultrasound (US) studies represent the ultrasonic imaging of retroperitoneal organs for the diagnosis and management of abnormalities that occur within the retroperitoneum. American College of Obstetricians and Gynecologists (ACOG). Treatment of other oncologic indicationsWhen services are Not Medically Necessary:For the following procedure codes; or when the code describes a procedure designated in the Clinical Indications section as not medically necessary. 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. Updated Coding section with 10/01/2017 ICD-10-CM diagnosis code changes. Zika virus was first reported in South America in May 2015 and since that time has now appeared in the United States. Ahmed HU, Zacharakis E, Dudderidge T, et al. 2017; 31(1):14-19. Evaluation of quality of life outcomes following palliative treatment of bone metastases with magnetic resonance-guided high intensity focused ultrasound: an international multicentre study. 2014; 20(28):9570-9577. 2013; 63(2):395-398. 2015; 56(2):503-509. Can J Urol. Available at: Limited obstetrical ultrasound examination. 2011; 185(4):1246-1254. The 2021 American Urological Association (AUA) published a guideline on renal mases and localized renal cancer. Urology. A complete resolution of pain at 1 year follow-up was shown in 2 participants (Joo, 2015). Non-Contact Ultrasound Treatment for Wounds; Non-Oncologic Uses of Rituximab (Rituxan) Nutritional Treatment of Childhood Medical Conditions; Ophthalmologic Techniques for Evaluating Glaucoma; Optical Diagnostic Devices for Evaluating Skin Lesions Suspected of Malignancy ; Oral Lesion Identification System (ViziLite, Velscope) Bone pain is a common complaint for individuals with metastatic cancer to the bone. ACOG Practice Bulletin 163. For other common visits, this is what you'll pay with PPO. These results were not included in the primary efficacy analysis. Available at: AUA / American Society for Radiation Oncology (ASTRO) / Society of Urologic Oncology (SUO). 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. ACOG Practice Bulletin 175. 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 . The SBC shows you how you and the Lawrentschuk N, Finelli A, Van der Kwast TH, et al. Updated Discussion, References and Websites for Additional Information sections. Our radiologists are among the most . 2005; 51(10):651-658. Systematic review of innovative ablative therapies for the treatment of locally advanced pancreatic cancer. TULSA is delivered by a system which includes real-time MR thermometry as well as robotically-driven directional thermal ultrasound in a closed loop system to ablate whole gland or targeted areas of the prostate. Review January 10, 2022. Ultrasound averages range from $54 to $100. October 2016. In a prospective, non-randomized single arm trial, MRgFUS was used on 5 individuals with painful bone metastatic lesions with a pain rating of 4 or higher. 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. Rombouts SJ, Vogel JA, van Santvoort HC, et al. The pain severity score was significantly reduced from a baseline mean of 7.1 (Standard Deviation[SD] 2.08) (4-10; 95% confidence interval [CI], 6.07-8.15), to 2.5 (SD 1.4) (0-5; 95% CI, 1.81-3.2) at 1 month. Harding D, Giles SL, Brown MRD, et al. MPTAC review. MPTAC review. Thuroff S, Chaussy C, Vallancien G, et al. Find top doctors who perform Rectal Ultrasound near you in Anthem, AZ. Breast MRI costs an average $615 under Medicare . : 20-EHC022. Blana A, Murat FJ, Walter B, et al. Updated Description, Discussion, References and Websites for Additional Information sections. Zhang M, Liu L, Wang J, et al. J Natl Cancer Inst. 2017; 69(1):93-100. Whitworth M, Bricker L, Mullan C. Ultrasound for fetal assessment in early pregnancy. PLoS One. Comparing high-intensity focal ultrasound hemiablation to robotic radical prostatectomy in the management of unilateral prostate cancer: a matched-pair analysis. The use of TULSA has been evaluated in several prospective and retrospective studies, with participants being treated for whole gland or partial gland ablation and as primary or salvage treatment as well as combined therapy for individuals with prostate cancer (Elterman, 2021; Lumiani, 2021; Ramsay, 2017). 2015; 2015(7):CD007058. The system protects the urethra and rectum via a water cooling system pumped through the applicator. Alldred SK, Takwoingi Y, Guo B, et al. Addition of cell-free fetal deoxyribonucleic acid (DNA) screening for aneuploidy to Medically Necessary Statement. Postpartum hemorrhage. 2014; 7(4):270-281. Uchida T, Baba S, Irie A, et al. 2009; 101(1):19-26. Siddiqui KM, Billia M, Arifin A, et al. Updated References section. 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 . Available at: High Intensity Ultrasound System For Prostate Tissue Ablation (Focal One). 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. Centers for Disease Control and Prevention (CDC). 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 . Medical Encyclopedia. June 7, 2018. 510K Premarket notification. Replaced term women with individual within clinical indications. Eur Urol. Updated Discussion/General Information, References and Websites for Additional Information sections. Ultrasound examinations can be used to assess fetal anatomy, particularly neuroanatomy, and to monitor growth. 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. We reserve the right to review and update Clinical UM Guidelines periodically. However, the change from baseline in MEDD intake was not statistically significant, although the authors noted a trend towards a statistically significant change. Practice Advisory Interim Guidance for Care of Obstetric Patients During a Zika Virus Outbreak. The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. Ann Surg Oncol. Anthem Blue Cross Blue Shield: Health Insurance, Medicare & More Learn more about your coverage options after the Public Health Emergency (PHE) ends. BJU Int. This study was defined by the regulatory agency to evaluate the effectiveness of the device to ablate prostate tissue. NOTE: Information about the cost of this plan (called the . PSA nadir as a predictive factor for biochemical disease-free survival and overall survival following whole-gland salvage HIFU following radiotherapy failure. Prostate Cancer Prostatic Dis. Napoli A, Anzidei M, De Nunzio C, et al. Reaffirmed October 2021. In 2016, ACOG and the SMFM released a practice advisory regarding the current information and recommendations regarding the Zika virus. 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. 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. Uchida T, Sanghvi NT, Gardner TA, et al. Federal and State law, as well as contract language, and Medical Policy take precedence over Clinical UM Guidelines. J Urol. Taneja SS. 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. The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Ultrasound is currently being used as a therapeutic treatment, for example, lithotripsy to disintegrate kidney stones. Principles and results of high-intensity focused ultrasound for localized prostate cancer. Revised 2020. $0 plans in select areas. American College of Radiology (ACR). Rejection notice to me (if I'm lucky) and I start over. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card. Available at: U.S. National Library of Medicine. Step 1: Report your pregnancy to your health plan. In a statement, Anthem says, "Anthem health plans cover 222 contraceptive products at $0 cost share on our ACA Preventive List." The company went on to say that it covers "at least one product" in . Prostate. Ahmed HU, Freeman A, Kirkham A, et al. Updated Discussion and References section. Updated June 13, 2019. Guidelines for diagnostic imaging during pregnancy and lactation. J Endourol. Crouzet S, Blana A, Murat FJ, et al. J Urol. Prudent use and safety diagnostic ultrasound in pregnancy. Updated References. The uterus, cervix, adnexa, and cul-de-sac region should be examined. Clin Orthop Relat Res. 2020; 22:79-87. We reserve the right to review and update Clinical UM Guidelines periodically. 2017. Summary of coverage and benefits PDF Service coverage and costs All employee health insurance plans provide one annual preventive care visit with your primary care provider at $0 co-pay within specified networks. High intensity focused ultrasound as first line salvage therapy in prostate cancer local relapse after radical prostatectomy: 4-year follow-up outcomes. While the analysis showed superior survival rates at 6 and 12 months in the groups which included HIFU in combination therapy, the authors noted that the overall quality of the studies was poor. 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. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. We have 53 properties for rent listed as: house bury, from 520.Find: bury properties for rent at the best prices We use cookies to personalize your Trovit experience on our site, analyze. Post-treatment biopsies were available in 77% of subjects. 2015; 194(1):114. 2000; 37(6):695-701. Clin Orthop Relat Res. 2008; 53(6):1194-1201. 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. Whole-gland ablation of localized prostate cancer with high-intensity focused ultrasound: oncologic outcomes and morbidity in 1002 patients. 2018; 6:8. HIFU has been proposed as a treatment for multiple oncologic conditions. There were no treatment-related AEs. * Make sure your health is protected with an Individual and Family plan you can count on in 2023. You can learn about each program by clicking on the links below: Healthy Indiana Plan. Urology. Hurwitz MD, Ghanouni P, Kanaev SV, et al. Nair SM, Hatiboglu G, Relle J, et al. Shah TT, Peters M, Kanthabalan A, et al. This document addresses the use of maternity ultrasound in the outpatient setting. 2015 Mar;34(3):435-440. Comprehensive medical coverage that covers many common services at no cost or for a low copay. Revised September 16, 2022. Chin JL, Billia M, Relle J, et al. J Endourol. Albisinni S, Aoun F, Bellucci S, et al. 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. Eur Urol. 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. Anthem BlueCross Coverage for: Individual + Family | Plan Type: HMO Anthem Value Ded HMO 750/25/40/25% The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. Uddin Ahmed H, Cathcart P, Chalasani V, et al. No ionizing radiation (x-ray) is used in ultrasound imaging. Focal therapy for localised unifocal and multifocal prostate cancer: a prospective development study. Dupr A, Melodelima D, Prol D, et al. Ahmed HU, Hindley RG, Dickinson L, et al. 2018. 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,. In 2012, the FDA approved via the Premarket Application (PMA) process, the ExAblate System (InSightec, Ltd, Dallas, TX) for pain palliation in individuals 18 years and older who have metastatic bone cancer pain and have failed, are not candidates for or have refused standard radiation therapy. Colombel M, Gelet A. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card. Zacharakis E, Ahmed HU, Ishaq A, et al. Available at: U.S. National Library of Medicine. The baseline median PSA of 7.6 ng/ml decreased to 0.23 ng/ml at 12 months follow-up. 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. MPTAC review. 2015; 102(8):873-882. 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. Available at: Centers for Disease Control and Prevention (CDC): How is Prostate Cancer Treated? Twelve-month prostate volume reduction after MRI-guided transurethral ultrasound ablation of the prostate. Beerlage HP, Thuroff S, Debruyne FM, et al. Yonsei Med J. 2018; 30(4):233-242. Focused ultrasound for the treatment of bone metastases: effectiveness and feasibility. Hemi salvage high-intensity focused ultrasound (HIFU) in unilateral radiorecurrent prostate cancer: a prospective two-centre study. Eur Urol Open Sci. Late complications included occurrences of stenosis (9%) and fistula (0.4%). MR-guided focused ultrasound (MRgFUS) ablation for the treatment of nonspinal osteoid osteoma: a prospective multicenter evaluation. 2006b; 97(1):56-61. In some states, insurance must cover . HIFU or MRgFUS has also been studied as a potential treatment of various cancers. 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. Ultrasound examinations can be used to assess fetal anatomy, particularly neuroanatomy, and to monitor growth. 2000; 14(6):519-528. Sofuni A, Moriyasu F, Sano T, et al. Focal salvage therapy for localized prostate cancer recurrence after external beam radiotherapy: a pilot study. The authors noted these results compared well to the radiation therapy complication rate. The PSA decreased from a median of 6.26 to 0.53 at 12 months. Magnetic resonance-guided focused ultrasound for patients with painful bone metastases: phase III trial results. Mol Urol. In an intent-to-treat analysis, 63% (72/115) were reported to have a complete histological response and had no evidence of cancer. The use of high intensity focused ultrasound (HIFU) is considered medically necessary for pain palliation in individuals with localized metastatic bone pain when all the following criteria are met: High intensity focused ultrasound (HIFU) is considered not medically necessary when the above criteria are not met and for all other indications, including but not limited to, the treatment of prostate cancer. HIFU or MRgFUS has also been studied as a potential treatment of various cancers. Results indicated that median survival in RFA, IRE and SBRT was more favorable compared to HIFU. Invest Radiol. 2010; 468(10):2825-2827. Approved May 19, 2020. Adult Cancer Pain (V2.2022). These resources can help members understand their maternity benefits. Available at: American Cancer Society. Coverage varies some from plan to plan, so check your plan's specifics. * From Jawad MU, Scully SP. American College of Obstetricians and Gynecologists (ACOG). J Urol. Contact us today for information about Anthem or for questions regarding Medicaid programs and coverage. Klotz L, Pavlovich CP, Chin J, et al. The authors concluded, Although newer modalities hold promise, we need higher quality studies to assess patient important outcomes to guide evidence-based clinical practice.. Muto S, Yoshii T, Saito K, et al. Required ultrasound or colonoscopy for select adult patients based on clinical scenario; Ultrasound-first approach for pediatric abdominal and pelvic pain . Kanthabalan A, Peters M, Van Vulpen M, et al. ( focal One ) salvage high-intensity focused ultrasound ( MRgFUS ) ablation for the group! 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