Nair SM, Hatiboglu G, Relle J, et al. Approved August 19, 2021. 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. Reapproved June 16, 2020. Prudent use and safety diagnostic ultrasound in pregnancy. J Urol. Before you decide to pass on Plan F, though, do your due diligence and see how much the insurance . High-intensity focused ultrasound for the treatment of localized prostate cancer: 5-year experience. 15727 Anthem Pkwy, Suite 600 . 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. AIUM practice guideline for the performance of obstetric ultrasound examinations. Adult Cancer Pain (V2.2022). Committee Opinion 723. Cancer. Invest Radiol. 2015; 28(3 Suppl):1097-1100. TULSA is delivered by a system which includes real-time MR thermometry as well as robotically-driven directional thermal ultrasound in a closed loop system to ablate whole gland or targeted areas of the prostate. 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 Updated Coding, Description, Discussion/General Information, and References. Updated References. Assessment of chorionicity is most accurate early in pregnancy and, because of the increased rate of complications associated with monochorionicity, determination of chorionicity by the late first trimester or early second trimester is important for counseling and caring for women with multifetal pregnancies. 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. Five years experience of transrectal high-intensity focused ultrasound using the Sonablate device in the treatment of localized prostate cancer. J Endourol. 2016; 47(4):530-532. Approximately 30% of all individuals with cancer develop metastatic bone lesions and 50-75% of these individuals report significant pain. 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. American College of Radiology (ACR). 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). In Ohio: Community Insurance Company. J Urol. Indiana Medicaid. There were 12 grade 3 adverse events (AEs) attributable to the TULSA-PRO, all of which were resolved by 12 months. Limani K, Aoun F, Holz S, et al. 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,. Available at. Locally recurrent prostate cancer after initial radiation therapy: early salvage high-intensity focused ultrasound improves oncologic outcomes. 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. Prostate Cancer. ACOG Practice Bulletin Number 229. This document addresses the use of maternity ultrasound in the outpatient setting. Improved outcomes with advancements in high intensity focused ultrasound devices for the treatment of localized prostate cancer. In November, the FDA approved the use of Ablatherm (Maple Leaf; Toronto, Canada) to treat prostate cancer in individuals who previously failed radiation therapy. Blana A, Murat FJ, Walter B, et al. 2015; 2015(6):CD001451. A complete retroperitoneal US study visualizes all the structures or organs within the anatomic description of that study. Ultrasound in pregnancy. The mean follow-up period was 6.4 years (range, 0.2-13.9). Ultrasound is currently being used as a therapeutic treatment, for example, lithotripsy to disintegrate kidney stones. World J Gastroenterol. The bone metastases arose from a variety of primary tumors including renal, colorectal, lung, breast and prostate. These results were not included in the primary efficacy analysis. 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. Pregnant Women. Pak J Pharm Sci. Int J Gynaecol Obstet. No ionizing radiation (x-ray) is used in ultrasound imaging. 1999b; 39(1):41-46. Eur Urol. The authors noted these results compared well to the radiation therapy complication rate. 2006b; 97(1):56-61. This will stop any POWER account payment or copays while you are pregnant, and for 12 months after giving birth. Zhang M, Liu L, Wang J, et al. $15 UK HEALTHCARE PRIMARY CARE CO-PAY $25 ANTHEM PRIMARY CARE CO-PAY $40 Available at: High Intensity Ultrasound System For Prostate Tissue Ablation (Focal One). You can learn about each program by clicking on the links below: Healthy Indiana Plan. These studies have a number of methodological limitations, including a lack of randomization of participants, a lack of a comparator group and limited follow-up for oncologic outcomes. 2017; 120(2):246-256. However, the change from baseline in MEDD intake was not statistically significant, although the authors noted a trend towards a statistically significant change. Prostate Cancer. Updated grammar in medically necessary statement regarding maternal risk factors from including but not limited to, hypertension, diabetes, sickle cell disease preeclampsia), substance abuse, or hyperemesis gravidarum to including but not limited to, hypertension, diabetes or sickle cell disease), preeclampsia, substance abuse or hyperemesis gravidarum. In an intent-to-treat analysis, 63% (72/115) were reported to have a complete histological response and had no evidence of cancer. Available at: Testing for Zika Virus Infections. Whole-gland salvage high-intensity focused ultrasound therapy for localized prostate cancer recurrence after external beam radiation therapy. The maternal cervix and adnexa should be examined. Magnetic resonance imaging-guided transurethral ultrasound ablation in patients with localised prostate cancer: 3-year outcomes of a prospective Phase I study. See the following related document for HIFU treatment non-oncologic indications: For information regarding other palliative treatments of metastatic bone lesions, please see the following: Metastatic lesions located 1 centimeter (cm) or greater from skin and major nerve bundles; Individual does not present an increased risk of fracture from the procedure (for example, a score of 7 or less on Mirels fracture risk score); Individual does not require surgical stabilization or have clinically significant comorbidities; Individual is not a candidate for other therapies as evidenced by pain refractory to previous radiation therapy. J Urol. Anthem Blue Cross Blue Shield: Health Insurance, Medicare & More Learn more about your coverage options after the Public Health Emergency (PHE) ends. 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. 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. Obstetric Care Consensus. The sound wave echoes are recorded and displayed as a real-time visual image. 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. However, residual tumors of less than 10% were found in 29.4% of cases and residual tumors between 10-90% were found in 22.7% of cases. Geiger D, Napoli A, Conchiglia A, et al. Palliative treatment: Treatment given for relief of symptoms and pain rather than attempting to cure. Errico A. 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. An individual with out-of-field recurrence underwent a repeat salvage TULSA. Pregnant Women. Whitworth M, Bricker L, Mullan C. Ultrasound for fetal assessment in early pregnancy. We are now accepting all Anthem Blue Cross Blue Shield patients. Guillaumier S, Peters M, Arya M, et al. The current evidence does not show that clinical outcomes of those undergoing TULSA is similar to those undergoing established alternatives. 2014; 20(28):9570-9577. Due to variances in utilization patterns, each plan may choose whether to adopt a particular Clinical UM Guideline. Urology. 2014; 65(5):907-914. Eur Urol Open Sci. Kaur A, Kaur A. Transvaginal ultrasonography in first trimester of pregnancy and its comparison with transabdominal ultrasonography. In addition, there are limitations on tissue tolerance at sites previously irradiated. 2003; 17(8):673-677. Transrectal high-intensity focused ultrasound in the treatment of localized prostate cancer. Anthem has begun denying coverage for . Nat Clin Pract Urol. 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. Beerlage HP, van Leenders GJ, Oosterhof GO, et al. Mol Urol. They determined that Cloyd had ovarian cysts, not appendicitis. The majority of attributable AEs were grade 1 or 2. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card. One of the largest of these studies was conducted by Ganzer and colleagues (2011). Focal salvage high-intensity focused ultrasound in radiorecurrent prostate cancer. Available at: Second and Third Trimester Vaginal Bleeding. Focused ultrasound for the treatment of bone metastases: effectiveness and feasibility. The difference in response rates between MRgFUS and placebo at 3 months was significant (64.3% versus 20.0%). Peek MC, Ahmed M, Napoli A, et al. Whole-gland ablation of localized prostate cancer with high-intensity focused ultrasound: oncologic outcomes and morbidity in 1002 patients. The recommendations are based on limited data. There are currently more than 125 Treatment Centers around the world using Insightec's Exablate Neuro platform to treat Essential Tremor. Retroperitoneal ultrasound (US) studies represent the ultrasonic imaging of retroperitoneal organs for the diagnosis and management of abnormalities that occur within the retroperitoneum. 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. BJU Int. MR-guided focused ultrasound (MRgFUS) ablation for the treatment of nonspinal osteoid osteoma: a prospective multicenter evaluation. 2021; 205(3):769-779. The SBC shows you how you and the plan would share the cost for covered health care services. Added Websites for Additional Information section. Re: Salvage high-intensity focused ultrasound for patients with recurrent prostate cancer after brachytherapy. 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. 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. Yutkin V, Ahmed HU, Donaldson I, et al. 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. The most relevant clinical information is obtained when serial exams are done at least three weeks apart, beginning no earlier than 18 weeks gestation. In addition to the active and pending Medical Policies, BCBSIL has included policies which are under development or being revised. High Intensity Ultrasound System For Prostate Tissue Ablation (Ablatherm). Urology. A multicentre study of 5-year outcomes following focal therapy in treating clinically significant nonmetastatic prostate cancer. close combat footage enemy visible bungee fitness dickson tn Tue, Oct 18 2022 Hemi salvage high-intensity focused ultrasound (HIFU) in unilateral radiorecurrent prostate cancer: a prospective two-centre study. High-intensity focused ultrasound and localized prostate cancer: efficacy results from the European multicentric study. 2017. 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. Federal and State law, as well as contract language, and Medical Policy take precedence over Clinical UM Guidelines. Clin Oncol (R Coll Radiol). Approved May 19, 2020. Anttinen M, Mkel P, Viitala A, et al. Birth Defects Homepage: Diagnosis. The SBC shows you how you and the plan would share the cost for covered health care services. 2022 Prenatal ultrasound diagnosis (Dx) codes Please note that this information is a guideline. Mirels scoring system: A scoring system based upon lesion characteristics and pain levels used to classify pathologic fracture risk. The authors theorized that the high rate of salvage treatment at 3 years follow-up could be attributed to suboptimal staging and treatment. 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. Zika virus was first reported in South America in May 2015 and since that time has now appeared in the United States. A total of 23 studies comprised of 1157 individuals were included. In the absence of specific indications, the optimal time for a single ultrasound examination is at 1822 weeks of gestation. Researchers used the visual analog pain score (VAS) to measure pain levels. J Endourol. There were no treatment-related AEs. Updated Discussion/General Information and Reference sections. MPTAC review. Updated Description, Discussion and References sections. Available at: American Cancer Society. Late complications included occurrences of stenosis (9%) and fistula (0.4%). Required ultrasound or colonoscopy for select adult patients based on clinical scenario; Ultrasound-first approach for pediatric abdominal and pelvic pain . 2020; 22:79-87. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Int J Urol. Cochrane Database Syst Rev. Prenatal ultrasound-series. The uterus, cervix, adnexa, and cul-de-sac region should be examined. The authors concluded, Although newer modalities hold promise, we need higher quality studies to assess patient important outcomes to guide evidence-based clinical practice.. Ahmed HU, Freeman A, Kirkham A, et al. Summary of Safety and Effectiveness Data (SSED). Updated Coding section; corrected ICD-10 diagnosis code O41.00X0. 2015; 193(1):103-110. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Comprehensive medical coverage that covers many common services at no cost or for a low copay. Of note, 65.7% (23/35) of individuals in the placebo group did not complete the 3-month follow-up compared to approximately 21% (26/112) of the MRgFUS group. American Urological Association (AUA). 2005; 19(6):693-701. 2018; 6:8. The prospective, nonrandomized, investigator-initiated, single-arm, single-center phase 1 study included 11 individuals with localized, histopathologically verified, radio-recurrent prostate cancer. 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. Statement on Biological Effects of Ultrasound in Vivo. U.S. Food and Drug Administration (FDA). 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