Peek MC, Ahmed M, Napoli A, et al. 2009; 101(1):19-26. PLoS One. 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). 2008; 38(3):192-199. 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. Grade 3 (n=1) and grade 2 (n=3) AEs related to urinary retention and urinary tract infection were reported. 2014; 11(6):303. Reaffirmed 2018. ACOG Practice Bulletin 175. 2014; 65(5):907-914. Updated Coding section with 10/01/2018 ICD-10-CM diagnosis code changes; added Q51.20-Q51.28, Z20.821. Screening for Fetal Aneuploidy. 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. 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). Int J Gynaecol Obstet. Pain palliation for localized metastatic bone pain. MPTAC review. National Coverage Determination: Ultrasound diagnostic procedures. These options carry their own risks and side effects. A total of 29 individuals underwent a follow-up biopsy, either at 12 months only, or at 12 and 36 months. Pain palliation for localized metastatic bone pain Bone pain is a common complaint for individuals with metastatic cancer to the bone. Cochrane Database Syst Rev. Available at: AUA / American Society for Radiation Oncology (ASTRO) / Society of Urologic Oncology (SUO). 2000; 4(3):183-187. The current standard treatment is external beam radiation therapy (EBRT). Effects of high-intensity focused ultrasound for treatment of abdominal lymph node metastasis from gastric cancer. 2016; 19(3):311-316. Available at: Centers for Disease Control and Prevention (CDC): How is Prostate Cancer Treated? 2018; 74(4):422-429. A complete retroperitoneal US study visualizes all the structures or organs within the anatomic description of that study. Magnetic resonance imaging-guided transurethral ultrasound ablation of prostate cancer. Bricker L, Medley N, Pratt JJ. 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. The authors concluded, Although newer modalities hold promise, we need higher quality studies to assess patient important outcomes to guide evidence-based clinical practice.. 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. MPTAC review. Ultrasound is currently being used as a therapeutic treatment, for example, lithotripsy to disintegrate kidney stones. Management of prostate-specific antigen relapse in prostate cancer: a European Consensus. High-intensity focused ultrasound for treatment of pancreatic cancer: a systematic review. 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. 2015; 28(3 Suppl):1097-1100. 2014; 114(4):532-540. The wait is over. Available at: Second and Third Trimester Vaginal Bleeding. 2012; 118(12):3071-3078. In 2015, The U.S. Food and Drug Administration (FDA) approved two devices for use in prostate cancer. Effectiveness of 12-13-week scan for early diagnosis of fetal congenital anomalies in the cell-free DNA era. 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. The mean reduction in the NRS score was significant between MRgFUS and placebo (3.6 3.1 versus 0.7 2.4). Committee Opinion 723. MPTAC review. No ionizing radiation (x-ray) is used in ultrasound imaging. 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. Can J Urol. Bone metastasis: When cancer cells have broken off from the primary tumor and have settled and started growing on bones. AIUM Practice Parameter for the Performance of Detailed Diagnostic Obstetric Ultrasound Examinations Between 12Weeks 0Days and 13Weeks 6Days. 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. Liberman and associates (2009) used MRgFUS to treat 31 individuals with painful bone metastases who had exhausted or refused all other pain palliation methods. July 25, 2018. TULSA is considered not medically necessary for any indication, including but not limited to prostate cancer. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card. Approved August 19, 2021. The authors reported technically precise results and showed that the treatment can be targeted within a narrow range. 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. Uddin Ahmed H, Cathcart P, Chalasani V, et al. Eur Urol. Eur Urology. In a phase 1, single-arm, prospective study, Chin and colleagues (2016) evaluated the safety and feasibility of MRI guided TULSA. There were no reported treatment related severe adverse events (AEs). Our radiologists are among the most . Number 7. 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). $15 UK HEALTHCARE PRIMARY CARE CO-PAY $25 ANTHEM PRIMARY CARE CO-PAY $40 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. MPTAC review. The resulting heat and cavitation destroys the targeted tissue. Elterman D, Li W, Hatiboglu G, et al. * From Jawad MU, Scully SP. The current evidence does not show that clinical outcomes of those undergoing TULSA is similar to those undergoing established alternatives. A statistically significant pain response was reported in 70.7% of this group. Prostate Cancer Prostatic Dis. Whole-gland ablation of localized prostate cancer with high-intensity focused ultrasound: oncologic outcomes and morbidity in 1002 patients. 2011; 185(3):862-868. 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. Harding D, Giles SL, Brown MRD, et al. Bonekamp and associates (2019) performed a quantitative analysis of viable prostate tissue volume reduction at 12 months post-procedure. 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. Ultrasound is currently being used as a therapeutic treatment, for example, lithotripsy to disintegrate kidney stones. This document does not address nuchal translucency. J Endourol. While some trials using HIFU to treat pancreatic or liver cancer have shown some promising results, these trials have lacked a comparator group (Chen, 2015; Dupr, 2015; Shi, 2015; Sofuni, 2014). ; AUA Prostate Cancer Clinical Guideline Update Panel. 2021; 205(3):769-779. Accessed on October 20, 2022. ACOG Practice Bulletin Number 171. Obstetric Care Consensus. Focal therapy with high-intensity-focused ultrasound in the treatment of localized prostate cancer. NOTE: Information about the cost of this plan (called the premium) will be . In 2021, Nair and colleagues reported the 3-year outcomes of the participants in the Chin study. 2011; 185(4):1246-1254. Revised June 27, 2022. Ultrasound Obstet Gynecol. HIFU treatment is combined with a visualization method, frequently MR guidance, to better guide treatment in real time. The PSA decreased from a median of 6.26 to 0.53 at 12 months. There are concerns about inconsistent treatment coverage within renal masses resulting in incomplete ablation. Chaussy C, Thuroff S. Results and side effects of high-intensity focused ultrasound in localized prostate cancer. BJU Int. Replaced term women with individual within clinical indications. Bonekamp D, Wolf MB, Roethke MC, et al. 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. HIFU is a non-invasive ablative procedure which has the advantage of sparing surrounding tissue which may reduce postoperative morbidity and hasten recovery. Salvage radical prostatectomy following primary high intensity focused ultrasound for treatment of prostate cancer. 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. Guillaumier S, Peters M, Arya M, et al. Sofuni A, Moriyasu F, Sano T, et al. . This document addresses the use of maternity ultrasound in the outpatient setting. HIFU or MRgFUS has also been studied as a potential treatment of various cancers. Step 1: Report your pregnancy to your health plan. NCCN Clinical Practice Guidelines in Oncology. Ultrasound averages range from $54 to $100. Quality of life following high-intensity focused ultrasound for the treatment of localized prostate cancer: a prospective study. Systematic review of innovative ablative therapies for the treatment of locally advanced pancreatic cancer. Blana A, Murat FJ, Walter B, et al. Eur Urol. J Ultrasound Med 2013; 32(6):1083-1101. Br J Surg. Pregnant Women. Revised 2020. The NCCN Prostate Cancer CPG (V1.2023) includes a recommendation for individuals with tumor recurrence following radiation therapy to include HIFU as a treatment option (2B recommendation). The document header wording updated from Current Effective Date to Publish Date. Updated Discussion/General Information, References and Websites for Additional Information sections. At 12 months, the majority of participants (10/11) were cancer free in the ablated area and maintained a low stable PSA. grievance or appeal. 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 . Ahmed HU, Cathcart P, McCartan N, et al. Reviewed and validity confirmed 2011. 2015 Mar;34(3):435-440. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. The SBC shows you how you and the 2001; 15(4):437-440. In 2013, Napoli and colleagues treated 18 individuals with painful bone metastases with MRgFUS. October 2016. The price of a diagnostic mammogram averages from $172 under Medicare to $239 with private insurance. 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. Taneja SS. Available at: Centers for Medicare and Medicaid Services. AIUM practice guideline for the performance of obstetric ultrasound examinations.
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