The five HIFU trials included a total of only 136 individuals. Indiana Medicaid for Members. 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. Hinyokika Kiyo. 2006a; 13(3):228-233. Focal therapy with high-intensity-focused ultrasound in the treatment of localized prostate cancer. Insurance coverage for whole-breast ultrasound is evolving. Results indicated that median survival in RFA, IRE and SBRT was more favorable compared to HIFU. BJU Int. 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). J Endourol. Pak J Pharm Sci. 2004; 63(4):625-629. -12/31/2022 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: HMO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan.The SBC shows you how you and the plan would share the cost for covered health care services. A total of 22 individuals participated in the follow-up. HIFU or MRgFUS has also been studied as a potential treatment of various cancers. Available at: American Cancer Society. Updated Discussion, References and Websites for Additional Information sections. Participants included those who could not undergo or refused all other available options for pain palliation. $0 virtual care, 24/7. December 2016. The resulting heat and cavitation destroys the targeted tissue. Hoosier Healthwise. 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. 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 . Search doctors, conditions, or procedures . The remaining 11.1% (2/18) reported pain reoccurrence which required pharmacological care. If maternal testing does not suggest infection, patients should receive the same ultrasound screening as any other pregnant woman as part of standard routine prenatal care. Prenatal ultrasound-series. 2015; 28(3 Suppl):1097-1100. Zip Code or City, State . The authors noted these results compared well to the radiation therapy complication rate. FAQ 133, July 2021. 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. The most commonly reported complications included Stress 1 urinary incontinence (18.7%), followed by obstruction of the bladder outlet (16.6%), and acute urinary retention (7.6%). 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. 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. J Endourol. J Urol. 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). Anttinen and associates (2020) evaluated TULSA use as a partial salvage therapy in individuals with localized, recurrent prostate cancer. There's Still Time To Enroll $0 preventive care. Crouzet S, Murat FJ, Pommier P, et al. Indiana Medicaid. Available at. 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. New 2020. The authors noted that incomplete tumor ablation could be related to poor accuracy in determining the target area or movement during the procedure. Klotz L, Pavlovich CP, Chin J, et al. 2005; 4(3):187-192. The system protects the urethra and rectum via a water cooling system pumped through the applicator. Focal salvage high-intensity focused ultrasound in radiorecurrent prostate cancer. In some states, insurance must cover . Schatzl G, Madersbacher S, Djavan B, et al. Gelet A, Chapelon JY, Poissonnier L, et al. 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. In Ohio: Community Insurance Company. Magnetic resonance imaging-guided transurethral ultrasound ablation of prostate tissue in patients with localized prostate cancer: a prospective Phase 1 clinical trial. Whole-gland ablation of localized prostate cancer with high-intensity focused ultrasound: oncologic outcomes and morbidity in 1002 patients. Br J Cancer. Centers for Disease Control and Prevention (CDC). 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). Radiother Oncol. 2006b; 97(1):56-61. Anthem has stopped covering patients in nine states 1 for MRI and CT scans performed in hospital outpatient settings - unless the exam qualifies for an "exception." On Nov. 15, Anthem will start retroactive reviews of MRI and/or CT services done in emergency departments in Missouri, Ohio and Kentucky. Chin JL, Billia M, Relle J, et al. Eur Urol Open Sci. CA/SG/Anthem Platinum PPO 15/250/10%/6BPB/01-22 Page 1 of 13 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: PPO Anthem Platinum PPO 15/250/10% The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. Surgery: MRgFUS-non invasive treatment for patients with painful bone metastasis. CA/IND/Anthem Silver 73 HMO/657G/01-22 Page 1 of 12 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 73 HMO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. American College of Obstetricians and Gynecologists (ACOG). 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. 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. 2004; 63(2):297-300. Gelet A, Chapelon JY, Bouvier R, et al. First clinical experience of intra-operative high intensity focused ultrasound in patients with colorectal liver metastases: a phase I-IIa study. Early prospective studies evaluating MRgFUS reported promising results. 2015; 56(2):503-509. A total of 23 studies comprised of 1157 individuals were included. Uchida T, Baba S, Irie A, et al. Palermo G, Totaro A, Sacco E, et al. July 25, 2018. Ultrasound: A screening or diagnostic technique in which very high frequency sound waves are passed into the body, and the reflected echoes are detected and analyzed to build a picture of the internal organs or of a single fetus or multiple fetuses in the uterus. The TULSA-PRO (Profound Medical Corp., Fort Myers, FL) received 510(k) clearance by the FDA in 2019. 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 . The prospective, nonrandomized, investigator-initiated, single-arm, single-center phase 1 study included 11 individuals with localized, histopathologically verified, radio-recurrent prostate cancer. * Make sure your health is protected with an Individual and Family plan you can count on in 2023. Bricker L, Medley N, Pratt JJ. Li CC, Wang YQ, Li YP, Li XL. 2016; 19(3):311-316. MPTAC review. Available at: Dahm P, Brasure M, Ester E, et al. Ultrasound examinations can be used to assess fetal anatomy, particularly neuroanatomy, and to monitor growth. Pain palliation in patients with bone metastases using MR-guided focused ultrasound surgery: a multicenter study. In those individuals who reported a decrease in pain levels, 50% (9/18) reported complete relief of pain, with 52% reporting significant pain relief beginning 3 days post treatment. 2004; 7(4):289-294. Baco E, Gelet A, Crouzet S, et al. 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) CPT codes Dx codes 76801 76802 D25, D25.0, D25.1, D25.2, D25.9, O0900, O0901, O0902, O0903, O09511, O09512, Salvage radical prostatectomy following primary high intensity focused ultrasound for treatment of prostate cancer. Available at: U.S. National Library of Medicine. It is completely automated and therefore extremely rigid. 2012; 116(3):201-205. We reserve the right to review and update Clinical UM Guidelines periodically. Harding D, Giles SL, Brown MRD, et al. 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. Last Reviewed: August 25, 2022. HIFU therapy was included in a comparative effectiveness review of clinically localized prostate cancer treatments (Dahm, 2020). The document header wording updated from Current Effective Date to Publish Date. Updated Discussion/General Information, References and Websites for Additional Information sections. AIUM-ACR-ACOG-SMFM-SRU Practice parameter for the performance of standard diagnostic obstetric ultrasound examinations. Assessment of fetal well being, in the absence of the signs, symptoms, or conditions listed above; Providing a keepsake picture of the baby for the parents. Crouzet S, Chapelon JY, Rouvire O, et al. Focal therapies are proposed as less invasive treatment options when compared to radical prostatectomy or radiation therapy. Systematic review of high-intensity focused ultrasound ablation in the treatment of breast cancer. Effectiveness of 12-13-week scan for early diagnosis of fetal congenital anomalies in the cell-free DNA era. 2014; 2014:186782. 2015; 2015(7):CD007058. 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. Transrectal high-intensity focused ultrasound for treatment of patients with stage T1b-2n0m0 localized prostate cancer: a preliminary report. Anthem Blue Cross Blue Shield: Health Insurance, Medicare & More Learn more about your coverage options after the Public Health Emergency (PHE) ends. Prudent use and safety diagnostic ultrasound in pregnancy. The wait is over. A complete retroperitoneal US study visualizes all the structures or organs within the anatomic description of that study. The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Ahhhhh! Technology insight: High-intensity focused ultrasound for urologic cancers. 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. Thuroff S, Chaussy C, Vallancien G, et al. 2005; 2(4):191-198. Updated Coding section; corrected ICD-10 diagnosis code O41.00X0. High intensity focused ultrasound ablation for patients with inoperable liver cancer. Comparing high-intensity focal ultrasound hemiablation to robotic radical prostatectomy in the management of unilateral prostate cancer: a matched-pair analysis. The available evidence does not support that the use of TULSA is clinically appropriate and an effective therapy compared to the standard treatments. Updated September 20, 2021. 1999b; 39(1):41-46. Twelve-month prostate volume reduction after MRI-guided transurethral ultrasound ablation of the prostate. June 7, 2018. Poggenpoel EJ, Geerts LT, Theron GB. Kenkhuis MJA, Bakker M, Bardi F, ET AL. The maternal cervix and adnexa should be examined. Available at. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. 1999a; 54(2):273-277. 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. An mpMRI, a transrectal ultrasound guided biopsy and a cystoscopy were performed at 12 months post-procedure. Day 1 health insurance coverage and comprehensive benefits options 401(k) matching program MPTAC review. HAIFA, Israel- MIAMI, Dec. 22, 2022/CNW/ -- Insightec, a global healthcare company dedicated to using acoustic energy to transform patient care, announced today that Anthem is the third national. At 2 weeks follow-up, all individuals experienced a decrease in VAS pain scores from baseline (1.5-5). In the obese patient, expectations regarding visualization of fetal anatomy should be tempered. Sofuni A, Moriyasu F, Sano T, et al. 2018. A clinically significant biopsy was reported in 34% (10/29) of participants with 59% (17/29) of participants reporting any positive biopsy. MPTAC review. Available at: High Intensity Ultrasound System for Prostate Tissue Ablation (TULSA-PRO System). The difference in response rates between MRgFUS and placebo at 3 months was significant (64.3% versus 20.0%). 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. 2018; 74(4):422-429. Available at. 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. Available at: U.S. National Library of Medicine. 2016; 70(3):447-455. Placenta Accreta Spectrum. Transrectal high-intensity focused ultrasound: minimally invasive therapy of localized prostate cancer. J Urol. 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 . Approximately 30% of all individuals with cancer develop metastatic bone lesions and 50-75% of these individuals report significant pain. Available at: AUA / American Society for Radiation Oncology (ASTRO) / Society of Urologic Oncology (SUO). 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. There were no treatment-related AEs. Cancer. 2012; 118(17):4148-4155. American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal Fetal Medicine (SMFM). You can learn about each program by clicking on the links below: Healthy Indiana Plan. ACOG Practice Bulletin Number 229. Eur Urol. Prostate cancer is the second leading cause of death with approximately 39,430 deaths in 2018 (Bekelman, 2018). Government Agency, Medical Society, and Other Authoritative Publications: The use of specific product names is illustrative only. National Coverage Determination: Ultrasound diagnostic procedures. Guillaumier S, Peters M, Arya M, et al. Plans include prescription drug and behavioral health coverage as well as telemedicine services and free AirMed medical transportation. Medical Encyclopedia. Medicare Supplement Plan F is great because it provides the most coverage of the 10 currently available MedSup plans. Ultrasound Obstet Gynecol. 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