The remaining 11.1% (2/18) reported pain reoccurrence which required pharmacological care. $15 UK HEALTHCARE PRIMARY CARE CO-PAY $25 ANTHEM PRIMARY CARE CO-PAY $40 PSA nadir as a predictive factor for biochemical disease-free survival and overall survival following whole-gland salvage HIFU following radiotherapy failure. The document header wording updated from Current Effective Date to Publish Date. Updated Discussion/General Information, References and Websites for Additional Information sections. 2011; 185(4):1246-1254. The five HIFU trials included a total of only 136 individuals. 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,. In the obese patient, expectations regarding visualization of fetal anatomy should be tempered. MPTAC review. Rockville (MD): Agency for Healthcare Research and Quality (US); 2020 Sep. Report No. Elterman D, Li W, Hatiboglu G, et al. Eur Urol. Chaussy C, Thuroff S. Results and side effects of high-intensity focused ultrasound in localized prostate cancer. Single high intensity focused ultrasound session as a whole gland primary treatment for clinically localized prostate cancer: 10-year outcomes. Hepatogastroenterology. In addition, eligible participants reported a numerical rating scale (NRS) pain score of 4 or greater in spite of maximal pain medication therapy, and a score of 7 or less on the Mirels fracture risk scale. Thompson I, Thrasher JB, Aus G, et al. Baco E, Gelet A, Crouzet S, et al. Available at: Testing for Zika Virus Infections. AIUM Practice Parameter for the Performance of Detailed Second- and Third-Trimester Diagnostic Obstetric Ultrasound Examinations. 2017. The sound wave echoes are recorded and displayed as a real-time visual image. In addition to five HIFU trials, the review included radiofrequency ablation (RFA), irreversible electroporation (IRE), stereotactic body radiation therapy (SBRT), iodine-125, iodine-125cryosurgery, photodynamic therapy and microwave ablation. 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). There are currently more than 125 Treatment Centers around the world using Insightec's Exablate Neuro platform to treat Essential Tremor. Ideally the ultrasound is done at the same appointment as the screening mammogram. CPT Only - American Medical Association, MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications, CG-SURG-61 Cryosurgical, Radiofrequency or Laser Ablation to Treat Solid Tumors Outside the Liver, https://acsearch.acr.org/docs/69397/Narrative, https://www.auanet.org/guidelines-and-quality/guidelines/renal-mass-and-localized-renal-cancer-evaluation-management-and-follow-up, https://www.astro.org/uploadedFiles/_MAIN_SITE/Patient_Care/Clinical_Practice_Statements/Content_Pieces/ClinicallyLocalizedProstateCancer.pdf, https://www.accessdata.fda.gov/cdrh_docs/pdf15/k153023.pdf, https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K172721, https://www.accessdata.fda.gov/cdrh_docs/pdf19/K191200.pdf, https://www.accessdata.fda.gov/cdrh_docs/pdf11/p110039b.pdf, http://www.cancer.org/treatment/understandingyourdiagnosis/bonemetastasis/bone-metastasis-treating-problems-caused, http://www.cdc.gov/cancer/prostate/basic_info/treatment.htm, https://medlineplus.gov/prostatecancer.html, https://www.nlm.nih.gov/medlineplus/palliativecare.html. Hurwitz MD, Ghanouni P, Kanaev SV, et al. 2015; 56(2):503-509. In a prospective, non-randomized single arm trial, MRgFUS was used on 5 individuals with painful bone metastatic lesions with a pain rating of 4 or higher. Peek and associates (2015) conducted a systematic review of the use of HIFU in breast cancer. Hematology/Oncology Subcommittee review. However, comparisons involving HIFU were limited to radical prostatectomy because of a lack of studies comparing HIFU to other therapies. CPT codes Dx codes 76801 76802 D25, D25.0, D25.1, D25.2, D25.9, O0900, O0901, O0902, O0903, O09511, O09512, Available at: High Intensity Ultrasound System For Prostate Tissue Ablation (Focal One). 2014; 7(4):270-281. In the 25 participants that were able to tolerate a complete treatment, 72% (18/25) reported significant pain reduction of at least 2 points on the VAS scale, 24% (6/25) reported no reduction in pain and 4% (1/25) reported an increase in pain levels. 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. P110039. 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. Participants included those who could not undergo or refused all other available options for pain palliation. Mol Urol. Clin Oncol (R Coll Radiol). 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 routine use of pulsed Doppler ultrasound to either document or listen to embryonic/fetal cardiac activity is discouraged. 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. 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). Pak J Pharm Sci. 2017; 3:CD012600. ACOG Practice Bulletin Number 183, October 2017. 2020; 22:79-87. There was 1 in-field and 2 out-of-field recurrences reported at that time. Available at: Dahm P, Brasure M, Ester E, et al. Safety trial of high-intensity focused ultrasound therapy for pancreatic cancer. NCCN Clinical Practice Guidelines in Oncology. PLoS One. Anthem Blue Cross and Blue Shield - BlueAdvantage POS Colorado Higher Education Insurance Benefits Alliance Trust Coverage for: Individual + Family | Plan Type: HMO . 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. 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. You bet! 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. HIP Maternity will cover enhanced benefits . Treatment of localized prostate cancer using high-intensity focused ultrasound. Sonablate was classified as a class II device. 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). Radical prostatectomy because of a lack of studies comparing HIFU to other therapies G, et al comparisons HIFU... Participants included those who could not undergo or refused all other available options for pain palliation in cancer... Pain palliation or refused all other available options for pain palliation, Brasure,... 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