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. June 7, 2018. Eur Urol. 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. Eur Urology. Systematic review of innovative ablative therapies for the treatment of locally advanced pancreatic cancer. The TULSA-PRO (Profound Medical Corp., Fort Myers, FL) received 510(k) clearance by the FDA in 2019. HIFU was comparable to the median survival in standard chemotherapy. Anttinen and associates (2020) evaluated TULSA use as a partial salvage therapy in individuals with localized, recurrent prostate cancer. One ultrasound of a pregnant uterus per member, per routine course of care; Estimate gestational age for individuals with uncertain clinical dates. The treatment group reported an AE frequency of 76.2% versus 23.8% in the sham group. The price of a diagnostic mammogram averages from $172 under Medicare to $239 with private insurance. Moved content of MED.00119 High Intensity Focused Ultrasound (HIFU) for Oncologic Indications to new clinical utilization management guideline document with the same title. 2006a; 13(3):228-233. Lancet Oncol. In brief: classifications in brief: Mirels' classification: metastatic disease in long bones and impending pathologic fracture. 2012; 105(2):198-202. Shi Y, Ying X, Hu X, et al. Approximately 30% of all individuals with cancer develop metastatic bone lesions and 50-75% of these individuals report significant pain. The recommendations are based on limited data. Br J Cancer. 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. $0 plans in select areas. ACR Appropriateness Criteria. Napoli A, Anzidei M, Marincola BC, et al. American College of Radiology (ACR). MPTAC review. A total of 22 individuals participated in the follow-up. MPTAC review. MPTAC review. There is insufficient evidence to draw conclusions about the effect of HIFU on urinary incontinence, erectile dysfunction or fecal incontinence when compared to radical prostatectomy. Hoosier Healthwise. 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). 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). Albisinni S, Aoun F, Bellucci S, et al. The guideline addresses several non-extirpative therapies and concluded that these therapies, including HIFU, are investigational for the treatment of renal masses. Approved August 19, 2021. . J Bone Joint Surg Am. Shah TT, Peters M, Kanthabalan A, et al. 2017; 119(6):896-904. Search doctors, conditions, or procedures . Prostate cancer is the second leading cause of death with approximately 39,430 deaths in 2018 (Bekelman, 2018). This document addresses ultrasound ablative therapy for the treatment of oncologic conditions. Updated References and Websites for additional information sections. On October 9, the FDA granted de novo clearance to SonaCare Medical, LLC (Charlotte, NC) to market the Sonablate 450 for prostate tissue ablation. ACOG Practice Bulletin 163. 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. Chaussy C, Thuroff S. Results and side effects of high-intensity focused ultrasound in localized prostate cancer. ACOG Practice Bulletin 175. J Urol. MPTAC review. Taneja SS. 2021; 127(5):544-552. However, there are no data specific to congenital Zika virus infection to guide recommendations for timing of serial ultrasounds; ob-gyns and other obstetric providers may consider extending the time interval between ultrasounds in accordance with patient preferences and clinical judgement. Prostate Cancer Prostatic Dis. Napoli A, Anzidei M, De Nunzio C, et al. Review January 10, 2022. High-intensity focused ultrasound (HIFU) followed after one to two weeks by radical retropubic prostatectomy: results of a prospective study. Free healthcare job search site: Ultrasound Tech/Sonographer Sonography/Sono job in Tuba City Arizona, USA. High-intensity focused ultrasound for the treatment of localized prostate cancer: 5-year experience. July 25, 2018. In addition to treatment, these individuals should undergo a sonographic fetal evaluation to evaluate for signs of fetal or placental syphilis. At 3 months, 72.2% (13/18) reported no pain without the use of pain medication, and 16.7% (3/18) reported a drop of at least 2 points on pain scale without an increase in pain medication. Reaffirmed October 2021. Ahhhhh! 2006b; 97(1):56-61. 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. When an embryo/fetus is detected, it should be measured, and the cardiac activity should be recorded by 2-D video clip or M-mode. 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. List Your Practice ; Search . HIFU or MRgFUS has also been studied as a potential treatment of various cancers. NCD #220.5. Last Reviewed: August 25, 2022. Sonablate was classified as a class II device. Anthem - Blue Cross Blue Shield Long awaited and much anticipated? The location you tried did not return a result. check_circle Item Saved! 2013; 48(6):351-358. Yutkin V, Ahmed HU, Donaldson I, et al. The current standard treatment is external beam radiation therapy (EBRT). Comparing high-intensity focal ultrasound hemiablation to robotic radical prostatectomy in the management of unilateral prostate cancer: a matched-pair analysis. Transrectal high-intensity focused ultrasound: minimally invasive therapy of localized prostate cancer. 2015; 10(2):e0118212. *Coverage includes fertility preservation . 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. Chaussy C, Thuroff S, Rebillard X, Gelet A. Updated Discussion/General Information, References and Websites for Additional Information sections. October 2016. Ultrasound Obstet Gynecol. 2004; 7(4):289-294. Pathological, oncologic and functional outcomes of a prospective registry of salvage high intensity focused ultrasound ablation for radiorecurrent prostate cancer. 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) 2015; 102(8):873-882. Cochrane Database Syst Rev. National Coverage Determination: Ultrasound diagnostic procedures. : 20-EHC022. J Endourol. J Evid Based Med. Eur Urol. The doctors in the emergency room did multiple tests including a CT scan and ultrasound. Individuals received either whole gland (n=8) or partial (n=8) ablation. Gelet A, Chapelon JY, Bouvier R, et al. Available at: U.S. National Library of Medicine. 2018; 51(4):463-469. 2011; 185(3):862-868. When services are Medically Necessary for routine anatomy screen and dating when criteria are met: Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks, 0 days), transabdominal approach; single or first gestation/each additional gestation [includes codes 76801, 76802], Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> 14 weeks 0 days), transabdominal approach; single or first gestation/each additional gestation [includes codes 76805, 76810], Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation/each additional gestation [includes codes 76811, 76812], Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses, Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus, Ultrasound, pregnant uterus, real time with image documentation, transvaginal. Please enter a valid 5-digit Zip Code. 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). J Endourol. You bet! We reserve the right to review and update Clinical UM Guidelines periodically. 2014; 2014:186782. Prudent use and safety diagnostic ultrasound in pregnancy. Sofuni A, Moriyasu F, Sano T, et al. Cancer. The majority of attributable AEs were grade 1 or 2. Ultrasound is currently being used as a therapeutic treatment, for example, lithotripsy to disintegrate kidney stones. 2009; 16(1):140-146. Mirels scoring system: A scoring system based upon lesion characteristics and pain levels used to classify pathologic fracture risk. Accessed on September 13, 2022. Clarification to Not Medically Necessary Statement. Visit our official site today for more details. Eur Urol. Medicare Supplement Plan F is great because it provides the most coverage of the 10 currently available MedSup plans. 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. Guideline for the management of clinically localized prostate cancer: 2007 update. Available at. The prospective, nonrandomized, investigator-initiated, single-arm, single-center phase 1 study included 11 individuals with localized, histopathologically verified, radio-recurrent prostate cancer. American College of Radiology (ACR). The remaining 11.1% (2/18) reported pain reoccurrence which required pharmacological care. Pregnant Women. . CT, digital radiography, ultrasound, mammography and DEXA equipment at each of our outpatient centers. Find a doctor near you. Transurethral ultrasound ablation (TULSA), which delivers directional thermal ultrasound via a catheter inserted into the urethra, is specific to prostate cancer. Before you decide to pass on Plan F, though, do your due diligence and see how much the insurance . TULSA was developed as an alternative method of prostate tissue ablation. MPTAC review. 2017. AIUM Practice Parameter for the Performance of Limited Obstetric Ultrasound Examinations by Advanced Clinical Providers. 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. 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 uterus, cervix, adnexa, and cul-de-sac region should be examined. 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. Indiana Medicaid. An mpMRI, a transrectal ultrasound guided biopsy and a cystoscopy were performed at 12 months post-procedure. MPTAC review. MPTAC review. Updated Description, Discussion, References and Websites for Additional Information sections. 2015; 193(1):103-110. 2005; 2(4):191-198. Bonekamp and associates (2019) performed a quantitative analysis of viable prostate tissue volume reduction at 12 months post-procedure. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card. This study was defined by the regulatory agency to evaluate the effectiveness of the device to ablate prostate tissue. For appeals related to well-being incentive credits, CO CHEIBA Custom Blue Priority PPO/BluePreferred Plan F 01 -20 1 of 15 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2021- 12/31/2021 Anthem Blue Cross and Blue Shield: Prime Blue Priority PPO Available at: American Cancer Society. 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. Uchida T, Tomonaga T, Kim H, et al. Zika Virus. Day 1 health insurance coverage and comprehensive benefits options 401(k) matching program The new Multiple Delivery policy has the same . 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. Nat Clin Pract Urol. Routine ultrasound in late pregnancy (after 24 weeks' gestation). HIP Maternity will cover enhanced benefits . Updated Coding section to add ICD-10-CM diagnosis codes O09.00-O09.03, O09.811-O09.829. Updated Coding section with 10/01/2017 ICD-10-CM diagnosis code changes. 2017; 69(1):93-100. When a growth disturbance is suspected clinically or there is a medical or obstetric condition that increases the risk of a growth disturbance, ultrasonography is the modality of choice to identify abnormal fetal growth. Updated References section. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card. Updated Coding section to include ICD-10-CM diagnosis codes Z36.0-Z36.9. 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 This document addresses the use of maternity ultrasound in the outpatient setting. The difference in response rates between MRgFUS and placebo at 3 months was significant (64.3% versus 20.0%). When services are Not Medically Necessary:For the procedure and diagnosis codes listed above when criteria are not met or for all other diagnoses not listed; or when the code describes a procedure or situation designated in the Clinical Indications section as not medically necessary. Clin Orthop Relat Res. 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. Find top doctors who perform Rectal Ultrasound near you in Anthem, AZ. 1999b; 39(1):41-46. 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. American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal Fetal Medicine (SMFM). Subtle second-trimester ultrasound markers should be interpreted in the context of a background risk based on the patients age, history, genetic screening, and serum screening results. Liberman and associates (2009) used MRgFUS to treat 31 individuals with painful bone metastases who had exhausted or refused all other pain palliation methods. 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. P110039. Uchida T, Ohkusa H, Yamashita H, et al. These results were not included in the primary efficacy analysis. Eur Urol. This prospective case series did not compare HIFU long-term survival and morbidity rates with the rates of other standard treatments. CPT codes Dx codes 76801 76802 D25, D25.0, D25.1, D25.2, D25.9, O0900, O0901, O0902, O0903, O09511, O09512, Whole-gland salvage high-intensity focused ultrasound therapy for localized prostate cancer recurrence after external beam radiation therapy. 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 Coding section with 10/01/2016 ICD-10-CM diagnosis code changes. The whole-breast ultrasound is designed to improve the detection rate of breast cancer in women with dense breasts, beyond what a mammogram alone can find. 2014; 7(4):270-281. Control of prostate cancer by transrectal HIFU in 227 patients. Baco E, Gelet A, Crouzet S, et al. Urology. Adverse events included grade 1 or 2 hematuria, urinary tract infections or acute urinary retention, and grade 3 epididymitis. The value of adding a universal booking scan to an existing protocol of routine mid-gestation ultrasound scan. * From Jawad MU, Scully SP. Postpartum hemorrhage. Guidelines for diagnostic imaging during pregnancy and lactation. Updated Discussion and References section. 15727 Anthem Pkwy, Suite 600 . The routine use of pulsed Doppler ultrasound to either document or listen to embryonic/fetal cardiac activity is discouraged. 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. Focal salvage therapy for localized prostate cancer recurrence after external beam radiotherapy: a pilot study. Update date: March 4, 2022. Focal therapies are proposed as less invasive treatment options when compared to radical prostatectomy or radiation therapy. Available at: Centers for Disease Control and Prevention (CDC). ACOG Practice Bulletin Number 229. For other common visits, this is what you'll pay with PPO. Klotz L, Pavlovich CP, Chin J, et al. 2015; 56(2):503-509. Available at: Limited obstetrical ultrasound examination. Li CC, Wang YQ, Li YP, Li XL. Revised title from High Intensity Focused Ultrasound (HIFU) for Oncologic Indications to Ultrasound Ablation for Oncologic Indications. Anthem has begun denying coverage for . J Urol. The resulting heat and cavitation destroys the targeted tissue. Revised September 16, 2022. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. J Urol. Indiana Medicaid provides coverage to pregnant women through two programs. At 12 months, the majority of participants (10/11) were cancer free in the ablated area and maintained a low stable PSA. 2004; 63(2):297-300. Updated Description, Coding, Discussion and References sections. Rockville (MD): Agency for Healthcare Research and Quality (US); 2020 Sep. Report No. Uchida T, Sanghvi NT, Gardner TA, et al. Focal therapy with high-intensity-focused ultrasound in the treatment of localized prostate cancer. Our radiologists are among the most . It is completely automated and therefore extremely rigid. Results indicated that median survival in RFA, IRE and SBRT was more favorable compared to HIFU. U.S. Food and Drug Administration (FDA). Available at: Testing for Zika Virus Infections. 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. Updated Coding section; corrected ICD-10 diagnosis code O41.00X0. Nat Rev Clin Oncol. Siddiqui KM, Billia M, Arifin A, et al. HIFU therapy was included in a comparative effectiveness review of clinically localized prostate cancer treatments (Dahm, 2020). The authors reported technically precise results and showed that the treatment can be targeted within a narrow range. MR-guided focused ultrasound (MRgFUS) ablation for the treatment of nonspinal osteoid osteoma: a prospective multicenter evaluation. . The maternal cervix and adnexa should be examined. * Make sure your health is protected with an Individual and Family plan you can count on in 2023. Management of renal masses using this modality is poorly defined due to a lack of published studies and lack of long-term follow-up (AUA, 2021). 2017; 3:CD012600. NOTE: Information about the cost of this plan (called the . An individual with out-of-field recurrence underwent a repeat salvage TULSA. grievance or appeal. The 2021 American Urological Association (AUA) published a guideline on renal mases and localized renal cancer. Available at: Magnetic Resonance guided Focused Ultrasound Surgery System (MRgFUS) ExAblate Model 2000/2100. However, the change from baseline in MEDD intake was not statistically significant, although the authors noted a trend towards a statistically significant change. Crouzet S, Blana A, Murat FJ, et al. 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.
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