2000; 14(6):519-528. 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. Required ultrasound or colonoscopy for select adult patients based on clinical scenario; Ultrasound-first approach for pediatric abdominal and pelvic pain . 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 . 2017. Ahmed HU, Freeman A, Kirkham A, et al. Updated Coding, Description, Discussion/General Information, and References. Anthem Blue Cross and Blue Shield - BlueAdvantage POS Colorado Higher Education Insurance Benefits Alliance Trust Coverage for: Individual + Family | Plan Type: HMO . Available at: Centers for Medicare and Medicaid Services. 2004; 63(2):297-300. 2012; 105(2):198-202. Available at: U.S. National Library of Medicine. 2011; 108(8 Pt 2):E196-E201. Clinically Localized Prostate Cancer: AUA/ASTRO/SUO Guideline. Taneja SS. Urology. 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. 2016; 70(3):447-455. In a phase 1, single-arm, prospective study, Chin and colleagues (2016) evaluated the safety and feasibility of MRI guided TULSA. 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). Int J Gynaecol Obstet. Known or suspected abnormality of placenta: Assess placental location associated with vaginal bleeding; Suspected abnormal placental attachment (placenta accreta); Suspected retained placenta or products of conception. Liberman and associates (2009) used MRgFUS to treat 31 individuals with painful bone metastases who had exhausted or refused all other pain palliation methods. . Yutkin V, Ahmed HU, Donaldson I, et al. Approved August 19, 2021. Dupr A, Melodelima D, Prol D, et al. Shoji S, Nakano M, Nagata Y, et al. Yonsei Med J. Medicare Supplement Plan F is great because it provides the most coverage of the 10 currently available MedSup plans. 2014; 11(6):303. Improved outcomes with advancements in high intensity focused ultrasound devices for the treatment of localized prostate cancer. Available at: High Intensity Ultrasound System For Prostate Tissue Ablation (Focal One). The PSA level, which had dropped following treatment, remained low. MPTAC review. Available at. Ultrasound imaging can be used after delivery to evaluate abnormalities of the reproductive and adjacent structures. Eur Urol. Anttinen M, Mkel P, Viitala A, et al. 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. Hinyokika Kiyo. TULSA is considered not medically necessary for any indication, including but not limited to prostate cancer. 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 current evidence does not show that clinical outcomes of those undergoing TULSA is similar to those undergoing established alternatives. 15727 Anthem Pkwy, Suite 600 . 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. Routine Tests During Pregnancy. 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. Available at. The routine use of pulsed Doppler ultrasound to either document or listen to embryonic/fetal cardiac activity is discouraged. 2018; 51(4):463-469. No ionizing radiation (x-ray) is used in ultrasound imaging. ACOG Practice Bulletin 163. Revised June 27, 2022. J Endourol. J Endourol. 2000; 37(6):695-701. In October 2017, ACOG and SMFM released an updated version of the practice advisory based upon updated Centers for Disease Control and Prevention (CDC) recommendations and recently published guidance. 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. Clin Oncol (R Coll Radiol). Available at: Antepartum Fetal surveillance. Review January 10, 2022. 2021; 35(4):497-505. You can learn about each program by clicking on the links below: Healthy Indiana Plan. Bone Metastases. Available at: Second and Third Trimester Vaginal Bleeding. Added medically necessary indication when there is a known or suspected exposure to the Zika virus to the Clinical Indications section. Ahmed HU, Hindley RG, Dickinson L, et al. Updated Coding section with 10/01/2022 ICD-10-CM changes; added O35.00X0-O35.9XX9 replacing O35.0XX0-O35.9XX9. The authors theorized that the high rate of salvage treatment at 3 years follow-up could be attributed to suboptimal staging and treatment. That coverage comes at a cost, however; specifically, Plan F is the most expensive of all the MedSup policies on the market today. Available at: Limited obstetrical ultrasound examination. Government Agency, Medical Society, and Other Authoritative Publications: Maternal UltrasoundObstetricPrenatalSonography. Rischmann P, Gelet A, Riche B, et al. New 2020. J Pharm Bioallied Sci. J Endourol. . American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal Fetal Medicine (SMFM). Int J Urol. Anthem has begun denying coverage for . Eur Urology. Pickles T, Goldenberg L, Steinhoff G. Technology review: high-intensity focused ultrasound for prostate cancer. July 25, 2018. There are currently more than 125 Treatment Centers around the world using Insightec's Exablate Neuro platform to treat Essential Tremor. 2006b; 97(1):56-61. Revised 2020. There are concerns about inconsistent treatment coverage within renal masses resulting in incomplete ablation. Shi Y, Ying X, Hu X, et al. 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. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. 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. Re: Salvage high-intensity focused ultrasound for patients with recurrent prostate cancer after brachytherapy. Available at: American Cancer Society. Plans include prescription drug and behavioral health coverage as well as telemedicine services and free AirMed medical transportation. The overall survival (OS) rate was 80%, the progression-free survival (PFS) rate was 94%, and the disease-specific survival rate was 97%. 2008; 38(3):192-199. At 2 weeks follow-up, all individuals experienced a decrease in VAS pain scores from baseline (1.5-5). 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. 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. The price of a diagnostic mammogram averages from $172 under Medicare to $239 with private insurance. AIUM-ACR-ACOG-SMFM-SRU Practice parameter for the performance of standard diagnostic obstetric ultrasound examinations. On October 9, the FDA granted de novo clearance to SonaCare Medical, LLC (Charlotte, NC) to market the Sonablate 450 for prostate tissue ablation. NOTE: Information about the cost of this plan (called the . Prostate. Management of preterm labor. BJU Int. An abnormal finding on second-trimester ultrasonography that identifies a major congenital anomaly significantly increases the risk of genetic abnormality and warrants further counseling, including the discussion of various prenatal testing strategies. The recommendations are based on limited data. When services are Not Medically Necessary:For the procedure and diagnosis codes listed above when criteria are not met. The wait is over. Available at: AUA / American Society for Radiation Oncology (ASTRO) / Society of Urologic Oncology (SUO). These resources can help members understand their maternity benefits. ACOG Practice Bulletin Number 171. You bet! 2008; 53(6):1194-1201. CT, digital radiography, ultrasound, mammography and DEXA equipment at each of our outpatient centers. Uchida T, Ohkusa H, Yamashita H, et al. 2012; 118(12):3071-3078. Guillaumier S, Peters M, Arya M, et al. 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. Adverse events included grade 1 or 2 hematuria, urinary tract infections or acute urinary retention, and grade 3 epididymitis. Cochrane Database Syst Rev. 2018; 74(4):422-429. Medical Policy & Technology Assessment Committee (MPTAC) review. Hoosier Healthwise. 2016; 47(4):530-532. Updated: June 16, 2022. High-intensity focused ultrasound for treatment of pancreatic cancer: a systematic review. J Ultrasound Med. Updated References and Websites for additional information sections. In the absence of specific indications, the optimal time for a single ultrasound examination is at 1822 weeks of gestation. 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. 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. Crouzet S, Blana A, Murat FJ, et al. Br J Surg. MPTAC review. 2019; 29(1):299-308. 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. Updated June 13, 2019. Accessed on September 13, 2022. BJU Int. Available at: ACOG. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. Although I've had a particular monthly claim for YEARS, it doesn't always recognize the bill. These Medical Policies serve as guidelines for health care benefit coverage decisions, which may vary according to the different products and benefit plans offered by BCBSIL. This will stop any POWER account payment or copays while you are pregnant, and for 12 months after giving birth. Assess vaginal bleeding of undetermined etiology; Assess abdominal or pelvic pain of undetermined etiology; Evaluation of fetal condition in late registrants for prenatal care; History of unexplained fetal demise in a previous pregnancy; Assess the fetus in cases with maternal risk factors such as family history of congenital abnormalities, chronic systemic disease (including but not limited to, hypertension, diabetes or sickle cell disease), preeclampsia, substance abuse or hyperemesis gravidarum; Assessment of fetus after abnormal serum Alpha Fetal Protein (AFP), serum screen or multiple analyte serum screen, or cell-free fetal deoxyribonucleic acid (DNA) screening for aneuploidy; Suspected ectopic pregnancy or hydatidiform mole, and to follow hydatidiform mole; Assess the fetus in cases of Rhesus (Rh) isoimmunization and other causes of fetal hydrops; Provide guidance for other testing, such as amniocentesis, chorionic villus sampling, and cordocentesis or procedures such as intrauterine blood transfusions or other in-utero fetal therapeutic procedures. Before you decide to pass on Plan F, though, do your due diligence and see how much the insurance . 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. 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. 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. Bone metastasesWhen services may be Medically Necessary when criteria are met: Unlisted procedure, musculoskeletal system, general [when specified as high intensity focused ultrasound ablation for pain palliation for bone metastases], Focused ultrasound ablation/therapeutic intervention, other than uterine leiomyomata, with magnetic resonance (MR) guidance. 2014; 96(9):743-751. * Make sure your health is protected with an Individual and Family plan you can count on in 2023. Therapies for clinically localized prostate cancer [Internet]. Jawad MU, Scully SP. 2005; 2(4):191-198. Magnetic resonance imaging-guided transurethral ultrasound ablation of prostate cancer. Revised May 20, 2020. Uchida T, Baba S, Irie A, et al. 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. 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. Although the exact mechanism of analgesic action of MRgFUS in pain palliation is unknown, studies have pointed to a few explanations. Prenatal ultrasound-series. 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. Pain severity was further reduced at the 3-month follow-up to 1 (SD 1.1) (0-3; 95% CI, 0-1.85) (p=0.001). This document addresses the use of maternity ultrasound in the outpatient setting. 2014; 106(5). 2005; 19(6):693-701. Can J Urol. J Urol. Available at: Dahm P, Brasure M, Ester E, et al. The Centers for Medicare and Medicaid Services (CMS) released an updated Relative Value file Jan. 5, that includes updated reimbursement for the neuromuscular ultrasound codes 76881, 76882 and 76883. 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. check_circle Item Saved! The 2021 American Urological Association (AUA) published a guideline on renal mases and localized renal cancer. As the bone cortex absorbs high ultrasound energy, periosteal denervation may ensue, resulting in pain relief. HIFU therapy was included in a comparative effectiveness review of clinically localized prostate cancer treatments (Dahm, 2020). Screening for Fetal Aneuploidy. Ultrasound Tech in San Antonio, Texas, United States. 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). Chen L, Wang K, Chen Z, et al. 2017; 197(1):97-102. Early prospective studies evaluating MRgFUS reported promising results. The benefits and limitations of ultrasonography should be discussed with all patients. Gardner TA, Koch MO. HIFU is a non-invasive ablative procedure which has the advantage of sparing surrounding tissue which may reduce postoperative morbidity and hasten recovery. Step 1: Report your pregnancy to your health plan. MPTAC review. High-intensity focused ultrasound in the treatment of primary prostate cancer: the first UK series. This document addresses ultrasound ablative therapy for the treatment of oncologic conditions. Invest Radiol. Anthem Blue Cross Blue Shield: Health Insurance, Medicare & More Learn more about your coverage options after the Public Health Emergency (PHE) ends. Prostate Cancer. Prostate Cancer (V1.2023). This study was defined by the regulatory agency to evaluate the effectiveness of the device to ablate prostate tissue. Rejection notice to me (if I'm lucky) and I start over. 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. December 2016. CPT Only - American Medical Association, RAD.00038 Use of 3-D, 4-D or 5-D Ultrasound in Maternity Care, https://www.acog.org/-/media/project/acog/acogorg/clinical/files/committee-opinion/articles/2017/10/guidelines-for-diagnostic-imaging-during-pregnancy-and-lactation.pdf, https://www.acog.org/clinical/clinical-guidance/obstetric-care-consensus/articles/2018/12/placenta-accreta-spectrum, https://www.acog.org/clinical/clinical-guidance/practice-bulletin, https://www.smfm.org/publications/220-acog-smfm-joint-practice-advisory-interim-guidance-for-care-of-obstetric-patients-during-a-zika-virus-outbreak, https://www.acr.org/-/media/ACR/Files/Practice-Parameters/US-OB.pdf, https://acsearch.acr.org/docs/69465/Narrative/?_ga=2.211725906.656052169.1601908671-191399006.1564351312, https://acsearch.acr.org/docs/3102400/Narrative/, https://www.aium.org/resources/guidelines/obstetric.pdf, https://www.aium.org/resources/statements.aspx, https://www.aium.org/resources/guidelines.aspx, https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf, https://www.cdc.gov/zika/hc-providers/types-of-tests.html, https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/ncd103c1_part4.pdf, https://www.acog.org/Patients/FAQs/Routine-Tests-During-Pregnancy, https://www.cdc.gov/ncbddd/birthdefects/diagnosis.html, https://www.cdc.gov/zika/prevention/index.html, https://medlineplus.gov/ency/presentations/100197_1.htm. Palliative treatment: Treatment given for relief of symptoms and pain rather than attempting to cure. One of the largest of these studies was conducted by Ganzer and colleagues (2011). There were 12 grade 3 adverse events (AEs) attributable to the TULSA-PRO, all of which were resolved by 12 months. We are now accepting all Anthem Blue Cross Blue Shield patients. Single high intensity focused ultrasound session as a whole gland primary treatment for clinically localized prostate cancer: 10-year outcomes. Locally recurrent prostate cancer after initial radiation therapy: early salvage high-intensity focused ultrasound improves oncologic outcomes. Urol Oncol. Eur Urol. Transrectal high-intensity focused ultrasound for treatment of patients with stage T1b-2n0m0 localized prostate cancer: a preliminary report. Focal high intensity focused ultrasound of unilateral localized prostate cancer: a prospective multicentric hemiablation study of 111 patients. Uddin Ahmed H, Cathcart P, Chalasani V, et al. Routine ultrasound in late pregnancy (after 24 weeks' gestation). Rombouts SJ, Vogel JA, van Santvoort HC, et al. Replaced term women with individual within clinical indications. 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). Prudent use and safety diagnostic ultrasound in pregnancy. In Ohio: Community Insurance Company. The most relevant clinical information is obtained when serial exams are done at least three weeks apart, beginning no earlier than 18 weeks gestation. Peek MC, Ahmed M, Napoli A, et al. For instance, if you want to take advantage of inversion therapy, massage, ultrasound therapy, or computer-assisted adjustments, youll need to ask your insurance company about the availability of coverage for these things . Eur Urol. Joo B, Park MS, Lee SH, et al. Anthem isn't the only insurer trying to find a way around hospitals' steeper costs for outpatient imaging, says Lea Halim, a senior consultant at the Advisory Board, a health care research and. The identified primary endpoint was the improvement in self-reported pain score without an increase in pain medication utilization at 3 months. Cancer. Low-Intensity Pulsed Ultrasound for Fracture Nonunion. 2002; 59(3):394-398. The guideline addresses several non-extirpative therapies and concluded that these therapies, including HIFU, are investigational for the treatment of renal masses. 2015; 28(3 Suppl):1097-1100. June 2021. J Urol. At 12 months, the majority of participants (10/11) were cancer free in the ablated area and maintained a low stable PSA. Eur Urol. In addition to treatment, these individuals should undergo a sonographic fetal evaluation to evaluate for signs of fetal or placental syphilis. AIUM practice guideline for the performance of obstetric ultrasound examinations. Revised September 16, 2022. In addition to the active and pending Medical Policies, BCBSIL has included policies which are under development or being revised. 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. Number 7. 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. For pregnant women with laboratory evidence of Zika infection, ultrasound to evaluate for fetal abnormalities consistent with congenital Zika virus syndrome is recommended. 2015; 56(2):503-509. 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. 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For Maternal fetal Medicine ( SMFM ) adverse events included grade 1 or 2 hematuria, urinary infections... Ahmed M, Nagata Y, et al Ohkusa H, et al Medicaid services added medically necessary when...
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