NOTE: Information about the cost of this plan (called the premium) will be . Researchers used the visual analog pain score (VAS) to measure pain levels. Correlation of prostate-specific antigen nadir and biochemical failure after high-intensity focused ultrasound of localized prostate cancer based on the Stuttgart failure criteria - analysis from the @-Registry. Single high intensity focused ultrasound session as a whole gland primary treatment for clinically localized prostate cancer: 10-year outcomes. 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). J Urol. 2014; 106(5). Ultrasound Tech in San Antonio, Texas, United States. Available at: American Institute of Ultrasound in Medicine (AIUM). Cancer. Reaffirmed 2021. Urology. Therapies for clinically localized prostate cancer [Internet]. Available at: Testing for Zika Virus Infections. 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. 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. Magnetic resonance imaging-guided transurethral ultrasound ablation in patients with localised prostate cancer: 3-year outcomes of a prospective Phase I study. Routine ultrasound in late pregnancy (after 24 weeks' gestation). Li CC, Wang YQ, Li YP, Li XL. 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. 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. The routine use of pulsed Doppler ultrasound to either document or listen to embryonic/fetal cardiac activity is discouraged. Zip Code or City, State . Shoji S, Nakano M, Nagata Y, et al. Crouzet S, Blana A, Murat FJ, et al. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. HIFU has been proposed as a treatment for multiple oncologic conditions. Invest Radiol. On October 9, the FDA granted de novo clearance to SonaCare Medical, LLC (Charlotte, NC) to market the Sonablate 450 for prostate tissue ablation. Approved May 19, 2020. High-intensity focused ultrasound in the treatment of primary prostate cancer: the first UK series. Medical Policy & Technology Assessment Committee (MPTAC) review. The current evidence is insufficient to support the use of HIFU as a generally accepted oncological treatment. Available at: Centers for Medicare and Medicaid Services. 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 Committee Opinion 723. J Urol. You can learn about each program by clicking on the links below: Healthy Indiana Plan. It is likely that both of these treatment effects contribute to pain relief. check_circle Item Saved! BJU Int. Shi Y, Ying X, Hu X, et al. J Ther Ultrasound. 2021; 127(5):544-552. 2014; 20(28):9570-9577. 2016; 70(3):447-455. Whole-gland salvage high-intensity focused ultrasound therapy for localized prostate cancer recurrence after external beam radiation therapy. MPTAC review. According to the FDA labeling, a nonunion is considered to be established when the fracture site shows no visibly progressive signs of healing. J Urol. Eur Urol. Summary of Safety and Effectiveness Data (SSED). This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for Ultrasound, Soft Tissues of Head and Neck. 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). The TULSA-PRO (Profound Medical Corp., Fort Myers, FL) received 510(k) clearance by the FDA in 2019. However, the change from baseline in MEDD intake was not statistically significant, although the authors noted a trend towards a statistically significant change. MPTAC review. Zacharakis E, Ahmed HU, Ishaq A, et al. Eur Urol. Accessed on September 13, 2022. Cochrane Database Syst Rev. 2020; 22:79-87. J Urol. Updated Coding, Description, Discussion/General Information, and References. Ultrasound during pregnancy is used to assess the uterus, umbilical cord and placenta, as well as fetal anatomy and well-being. Primary pain palliation and local tumor control in bone metastases treated with magnetic resonance-guided focused ultrasound. 2010; 468(10):2825-2827. Updated References and Websites for additional information sections. Ultrasound Obstet Gynecol. Available at: Centers for Disease Control and Prevention (CDC). 2004; 58(4):382-390. 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. 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. The mean follow-up period was 6.4 years (range, 0.2-13.9). Practice Advisory Interim Guidance for Care of Obstetric Patients During a Zika Virus Outbreak. Whole-gland ablation of localized prostate cancer with high-intensity focused ultrasound: oncologic outcomes and morbidity in 1002 patients. Available at: American Cancer Society. J Endourol. 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. Hinyokika Kiyo. Zhang M, Liu L, Wang J, et al. 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. 2003; 17(8):673-677. Late complications included occurrences of stenosis (9%) and fistula (0.4%). Systematic review of innovative ablative therapies for the treatment of locally advanced pancreatic cancer. 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. Federal and State law, as well as contract language, and Medical Policy take precedence over Clinical UM Guidelines. 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. 15727 Anthem Pkwy, Suite 600 . 2015; 10(2):e0118212. There were no new reported serious AEs. The treatment group reported an AE frequency of 76.2% versus 23.8% in the sham group. Individuals received either whole gland (n=8) or partial (n=8) ablation. 2002; 59(3):394-398. The authors noted these results compared well to the radiation therapy complication rate. Low-Intensity Pulsed Ultrasound for Fracture Nonunion. Updated Description, Discussion, References and Websites for Additional Information sections. 2019; 29(1):299-308. 2005; 2(4):191-198. Insurance coverage for whole-breast ultrasound is evolving. . 2011; 108(8 Pt 2):E196-E201. BJU Int. 2015; 193(1):103-110. Crouzet S, Murat FJ, Pommier P, et al. 2006a; 13(3):228-233. 2005; 12(2):2593-2597. 2018; 51(4):463-469. Gelet A, Chapelon JY, Poissonnier L, et al. 1999b; 39(1):41-46. The American College of Obstetricians and Gynecologists (ACOG) 2018 Practice Bulletin Ultrasound in Pregnancy lists the following recommendations: The following conclusions are based on good and consistent evidence (Level A): The following conclusions are based on limited or inconsistent evidence (Level B): The following conclusion and recommendation are based primarily on consensus and expert opinion (Level C): The American College of Radiology (ACR), the American Institute of Ultrasound in Medicine (AIUM), ACOG, the Society for Maternal Fetal Medicine (SMFM), and the Society of Radiologists in Ultrasound (SRU) practice parameter (2018) notes: A standard obstetrical ultrasound examination in the first trimester includes evaluation of the presence, size, location, and number of gestational sac(s). In the obese patient, expectations regarding visualization of fetal anatomy should be tempered. ultrasound). The anthem blue cross rehab coverage is depending on the location of the policyholder and the specifics of their plan. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card. J Urol. Available at: AUA / American Society for Radiation Oncology (ASTRO) / Society of Urologic Oncology (SUO). Joo B, Park MS, Lee SH, et al. High-intensity focused ultrasound (HIFU) followed after one to two weeks by radical retropubic prostatectomy: results of a prospective study. As of January 10, 2022, through January 31, 2022, Anthem and its delegated entities will suspend select prior authorization requirements to allow healthcare providers to focus on caring for patients diagnosed with COVID-19. Last Reviewed: August 25, 2022. 2013; 48(6):351-358. HIFU or MRgFUS has also been studied as a potential treatment of various cancers. 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. Uchida T, Ohkusa H, Nagata Y, et al. HIFU or MRgFUS has also been studied as a potential treatment of various cancers. Updated References section. A statistically significant pain response was reported in 70.7% of this group. Reviewed and validity confirmed 2011. Pregnant Women. Clin Genitourin Cancer. Transrectal high-intensity focused ultrasound in the treatment of localized prostate cancer. MedlinePlus. Placenta Accreta Spectrum. The authors reported technically precise results and showed that the treatment can be targeted within a narrow range. MedlinePlus. 2012; 105(2):198-202. August 15, 2019. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia . Providers are responsible for billing the appropriate CPT code, modifier, and diagnosis combinations. List Your Practice ; Search . A total of 22 individuals participated in the follow-up. Ahmed HU, Freeman A, Kirkham A, et al. 2010; 17(8):715-719. Eur Radiol. 2004; 63(4):625-629. 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. 2014; 65(5):907-914. 2015; 62(137):140-143. Recommendations for the management of a pregnant individuals with suspected Zika virus infection include: The 2021 CDC guideline on the treatment of sexually transmitted infections includes management recommendations for individuals who are diagnosed with text in the second half of pregnancy. 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. High Intensity Ultrasound System For Prostate Tissue Ablation (Ablatherm). Focal salvage therapy for localized prostate cancer recurrence after external beam radiotherapy: a pilot study. Colombel M, Gelet A. *Coverage includes fertility preservation . Baco E, Gelet A, Crouzet S, et al. J Ultrasound Med. MPTAC review. After excluding the drop-out groups the results remained similarly statistically significant. June 2021. In the first phase III study published, Hurwitz and colleagues (2014) conducted a randomized, placebo-controlled, single-blind, multicenter, pivotal trial which included 147 participants with bone metastases from breast, prostate, kidney, lung or other primary tumors. , United States to pain relief Nakano M, Liu L, YQ. Anthem blue cross rehab coverage is depending on the member 's card 108 ( Pt! Premium ) will be 23.8 % in the follow-up the use of pulsed ultrasound! Noted these results compared well to the FDA labeling, a nonunion is considered to be when... In 1002 patients ) clearance by the FDA labeling, a nonunion is considered be... ( VAS ) to measure pain levels a whole gland ( n=8 ) or partial ( n=8 ).! 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