Ultrasound imaging, also called ultrasound scanning or sonography, is a method of obtaining images of internal organs by sending high-frequency sound waves into the body. ultrasound). 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. Number 7. MPTAC review. 2021; 127(5):544-552. Single high intensity focused ultrasound session as a whole gland primary treatment for clinically localized prostate cancer: 10-year outcomes. 2021: S1078-1439(21)00173-3. At 12 months, the majority of participants (10/11) were cancer free in the ablated area and maintained a low stable PSA. They determined that Cloyd had ovarian cysts, not appendicitis. 2014; 7(4):270-281. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. 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. Peek MC, Ahmed M, Napoli A, et al. Summary of Safety and Effectiveness Data (SSED). Cochrane Database Syst Rev. Results indicated that median survival in RFA, IRE and SBRT was more favorable compared to HIFU. Transrectal high-intensity focused ultrasound: minimally invasive therapy of localized prostate cancer. Two-year results of transurethral resection of the prostate versus four 'less invasive' treatment options. Available at: AUA / American Society for Radiation Oncology (ASTRO) / Society of Urologic Oncology (SUO). Providers are responsible for billing the appropriate CPT code, modifier, and diagnosis combinations. Pregnant Women. Review January 10, 2022. 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, respectively. Pregnant Women. Coverage varies some from plan to plan, so check your plan's specifics. AIUM practice guideline for the performance of obstetric ultrasound examinations. Ahmed HU, Cathcart P, McCartan N, et al. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card. Management of preterm labor. 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. Available at: U.S. National Library of Medicine. Reaffirmed October 2021. Magnetic resonance imaging-guided transurethral ultrasound ablation in patients with localised prostate cancer: 3-year outcomes of a prospective Phase I study. In a systematic review, Li and colleagues (2014) performed a meta-analysis on the use of HIFU in combination with radiotherapy or chemotherapy in the treatment of pancreatic cancer. close combat footage enemy visible bungee fitness dickson tn Tue, Oct 18 2022 MPTAC review. 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). Clin Genitourin Cancer. The current evidence does not show that clinical outcomes of those undergoing TULSA is similar to those undergoing established alternatives. Li CC, Wang YQ, Li YP, Li XL. Cochrane Database Syst Rev. For appeals related to well-being incentive credits, Errico A. Federal and State law, as well as contract language, and Medical Policy take precedence over Clinical UM Guidelines. 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. Updated Coding section with 10/01/2020 ICD-10-CM changes; added O99.891; removed Q51.20 deleted 09/30/2020. Whole-gland salvage high-intensity focused ultrasound therapy for localized prostate cancer recurrence after external beam radiation therapy. Prostate. 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. Gelet A, Chapelon JY, Poissonnier L, et al. In the obese patient, expectations regarding visualization of fetal anatomy should be tempered. American College of Radiology (ACR). 2021; 35(4):497-505. ACOG Practice Bulletin Number 171. These resources can help members understand their maternity benefits. 2018; 74(4):422-429. MPTAC review. 2005; 19(6):693-701. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. MRI-TULSA resulted in an 88% reduction of viable prostate tissue volume. Eur Urol. 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. Urology. Adverse events included grade 1 or 2 hematuria, urinary tract infections or acute urinary retention, and grade 3 epididymitis. High intensity focused ultrasound (HIFU) or magnetic resonance guided focused ultrasound (MRgFUS) involves the use of a focused high-intensity convergent ultrasound beam to destroy targeted tissue in a small, focused area via sonication. Ultrasound examinations can be used to assess fetal anatomy, particularly neuroanatomy, and to monitor growth. Updated Coding section with additional diagnosis codes D25.0-D25.9, O26.872-O26.879, O99.210-O99.213, O99.810. 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 . In a phase 1, single-arm, prospective study, Chin and colleagues (2016) evaluated the safety and feasibility of MRI guided TULSA. 2001; 15(4):437-440. Gardner TA, Koch MO. Following treatment, no residual tumor was found in 46.2% of cases. Bonekamp D, Wolf MB, Roethke MC, et al. AIUM Practice Parameter for the Performance of Detailed Second- and Third-Trimester Diagnostic Obstetric Ultrasound Examinations. National Coverage Determination: Ultrasound diagnostic procedures. Revised May 20, 2020. Replaced term women with individual within clinical indications. Reformatted Coding section. Updated Description, Discussion and References sections. 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. Clin Oncol (R Coll Radiol). P110039. 2009; 101(1):19-26. Eur Urol. High-intensity focused ultrasound for treatment of pancreatic cancer: a systematic review. Bricker L, Medley N, Pratt JJ. 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. Ann Surg Oncol. J Evid Based Med. Liberman B, Gianfelice D, Inbar Y, et al. 2012; 118(17):4148-4155. Uchida T, Ohkusa H, Nagata Y, et al. Kenkhuis MJA, Bakker M, Bardi F, ET AL. Magnetic resonance-guided focused ultrasound for patients with painful bone metastases: phase III trial results. Zip Code or City, State . Thompson I, Thrasher JB, Aus G, et al. November 6, 2015. The system protects the urethra and rectum via a water cooling system pumped through the applicator. New 2020. 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. Available at: Centers for Disease Control and Prevention (CDC). Baco E, Gelet A, Crouzet S, et al. The difference in response rates between MRgFUS and placebo at 3 months was significant (64.3% versus 20.0%). It is completely automated and therefore extremely rigid. Updated: June 16, 2022. 2012; 118(12):3071-3078. 1999a; 54(2):273-277. Transurethral ultrasound ablation (TULSA), which delivers directional thermal ultrasound via a catheter inserted into the urethra, is specific to prostate cancer. $0 virtual care, 24/7. 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. 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