Cryosurgical Ablation of the Prostate Clinical Medical Policy Department Clinical Affairs Division

Clinical Medical Policy Department
Clinical Affairs Division
Cryosurgical Ablation of the Prostate
[For the list of services and procedures that need preauthorization, please refer to www.mcs.com.pr go to “Comunicados a Proveedores”,
and click “Cartas Circulares”.]
Medical Policy:
Original Effective Date:
Revised:
Next Revision:
MP-SU-02-07
December 22, 2007
October 22, 2014
August, 2015
This policy applies to products subscribed by the following corporations, MCS Life Insurance Company (Commercial), and MCS Advantage,
Inc. (Classicare) and Medical Card System, Inc., provider’s contract; unless specific contract limitations, exclusions or exceptions
apply. Please refer to the member’s benefit certification language for benefit availability. Managed care guidelines related to referral
authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply subject to the
aforementioned exceptions.
DESCRIPTION
Cryosurgery of the prostate gland, also known as Cryosurgical Ablation of the Prostate (CAP), destroys
prostate tissue by applying extremely cold temperature in order to reduce the size of the prostate gland.
An Ultrasound or magnetic resonance imaging (MRI) is use to help to guide the cryoprobe and monitor
the freezing of the cells to avoid collateral damage to nearby healthy tissue.
COVERAGE
Benefits may vary between groups and contracts. Please refer to the appropriate member certificate
and subscriber agreement contract for applicable diagnostic imaging, DME, laboratory, machine tests,
benefits and coverage.
INDICATIONS
Medical Card System (MCS) considers Cryosurgical Ablation of the Prostate (CSAP) medically
reasonable and necessary as primary treatment for:
1. Clinically localized prostate cancer Stage T1 (i.e., clinically in apparent tumors), Stage T2 (i.e.,
tumor confined within the prostate), Stage T3 (i.e., tumor locally advanced) when lymph nodes
are negative for cancer.
2. Salvage cryosurgery of prostate after radiation failure for:
a. Having recurrent, localized prostate cancer;
b. Have failed a trial of radiation therapy as their primary treatment; AND
This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract.
Medical technology is constantly changing and we reserves the right to review and update our policies periodically.
Medical Card System, Inc.
All Rights Reserved®
1
Clinical Medical Policy Department
Clinical Affairs Division
c. Meet one of these conditions:



Stage T2B or below
Gleason Score < 9
PSA < 8ng/mL
CONTRAINDICATIONS/LIMITATIONS
1. Cryosurgery as salvage therapy is not covered after failure of other therapies as the primary
treatment.
2. Salvage Cryosurgery of Prostate will be contraindicated only in members where radiation therapy
trial fail and the conditions noted above are not met.
3. If the patient has a very large prostate. In this case patient may be required to have hormone
treatment first to shrink the prostate to an appropriate size.
4. If the patient has had prior TURP (Transurethral Prostatectomy) surgery which has left a large
defect.
5. If the patient has any rectal pathology or disease such as rectal stenosis.
6. If patient suffers from inflammatory bowel disease with fistula formation.
7. If patient has had previous pelvic surgery; scarring may interfere with ability to perform procedure.
8. If the patient has had a significant symptom of urinary tract obstruction; may not be ideal
candidates for cryotherapy.
CODING INFORMATION
CPT® CODES (LIST MAY NOT BE ALL INCLUSIVE)
CPT® Codes
55873
Description
Cryosurgical ablation of the prostate (includes ultrasonic guidance and monitoring)
Current Procedural Terminology (CPT®) 2014 American Medical Association: Chicago, IL.
ICD-9 CM® DIAGNOSIS CODES (LIST MAY NOT BE ALL INCLUSIVE)
ICD-9 CM®
Codes
185
233.4
Description
Malignant Neoplasm of Prostate
Carcinoma in Situ (prostate)
This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract.
Medical technology is constantly changing and we reserves the right to review and update our policies periodically.
Medical Card System, Inc.
All Rights Reserved®
2
Clinical Medical Policy Department
Clinical Affairs Division
236.5
239.5
Neoplasm of uncertain behavior of (prostate)
Neoplasm of unspecified nature (other genitourinary organs)
2014 ICD-9-CM®For Physicians, VOLUMES I & II, Professional Edition (American Medical Association)
HCPCS® CODES (List may not be all inclusive)
HCPCS Codes
C2618
Description
Probe/needle, Cryoablation
2014 HCPCS LEVEL II Professional Edition® (American Medical Association).
ICD-10 Codes (Preview Draft)
In preparation for changes in the coding systems form ICD- 9 to ICD -10, this policy includes a sample list
of ICD-10 codes for your reference. These codes may become subject to changes or modifications since
they will be in effect on October 1, 2015.
ICD-10-Codes
C61
D07.5
D40.0
D49.5
DESCRIPTION
Malignant neoplasm of prostate
Carcinoma in situ of prostate
Neoplasm of uncertain behavior of prostate
Neoplasm of unspecified behavior of other genitourinary organs
REFERENCES
1. Centers for Medicare and Medicaid (CMS), Coverage Issue Manual, section 35-96. Accessed
August 20, 2014. Available at URL address:
http://www.dmerc.com/manual/medical%20procedures.htm#_1_100 &
https://www.cms.gov/transmittals/downloads/R145CIM.pdf
2. Centers for Medicare and Medicaid (CMS), Manual System Pub 100-04 Medicare Claims
Processing, Transmittal 1111, Change Request 5376, Dated: November 9, 2006. Accessed
August 20, 2014. Available at URL address:
http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/downloads/R1111CP.pdf
3. Centers for Medicare and Medicaid (CMS), Medicare Claims Processing Manual, Chapter 18
Preventive and Screening Services. Rev. 2824. Section 50.1. Dated: Nov 22, 2013. Accessed
August 20, 2014. Available at URL address:
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c18.pdf
This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract.
Medical technology is constantly changing and we reserves the right to review and update our policies periodically.
Medical Card System, Inc.
All Rights Reserved®
3
Clinical Medical Policy Department
Clinical Affairs Division
4. Centers for Medicare and Medicaid (CMS), Medicare Processing Manual, Chapter 32-Billing
Requirements for Special Services, Transmittal for Chapter 32, 180 - Cryosurgery of the Prostate
Gland, 180.1-Coverage Requirements, 180.2-Billing Requirements, 180.3-Payment
Requirements. Rev. 2989, Last Revision: 07/18/2014. Rev. 2998, Last Revision: 07/25/18.
Accessed August 20, 2014. Available at URL address:
https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/clm104c32.pdf
5. Centers for Medicare and Medicaid (CMS), National Coverage Determination (NCD) for
Cryosurgery of Prostate, Section, (230.9). Effective Date: 7/01/2001. Accessed August 20, 2014.
Available at URL address: http://www.cms.gov/medicare-coverage-database/details/ncddetails.aspx?NCDId=123&ncdver=1&bc=AgAAQAAAAAAA& or
http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/ncd103c1_part4.pdf
6. Duke K. Bahn, MD and Paul Silverman, MD. The Prostate Cancer Research Institute (PCRI)
Cryoablation of the Prostate. February 2005 Vol. 8. No. 1. Accessed August 20, 2014. Available
at URL address: http://prostate-cancer.org/cryoablation-of-the-prostate/
7. ECRI. Technology update: cryosurgical ablation of the prostate. Plymouth Meeting (PA): 2009
(Executive Briefings). Searched August 20, 2014. (Document not available at www.ecri.org)(Document available at MCS electronic folder).
8. ECRI. [technology assessment] - Cryoablation for prostate cancer. Plymouth Meeting (PA): April
30, 2008. Searched August 20, 2014. (Document not available at www.ecri.org)- (Document
available at MCS electronic folder).
9. Food and Drug Administration (FDA) website. 510 summaries # Letter K042667. Accessed
August 20, 2014. Available at URL address:
http://www.accessdata.fda.gov/cdrh_docs/pdf4/k042667.pdf
10. Gregory T. Sweat, M.D. Guiding Prostate Cancer Treatment choices, Early detection means more
options for more men. Post Graduate. Medicine Vol. 117. No. 4. April 2005. Pag: 45-50.
Accessed August 20, 2014. Available at URL address:
http://www.ncbi.nlm.nih.gov/pubmed/15842132
11. Jeffrey K. Cohen, Ralph J. Miller, Ju, Gina M. Rooker and Barry A. Shaman, Medical Article,
Cryosurgical Ablation of Prostate: Two year Prostate Specific Antigen and Biopsy Results.
Accessed August 20, 2014. Available at URL address:
http://www.goldjournal.net/article/S0090-4295(99)80459-2/abstract
This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract.
Medical technology is constantly changing and we reserves the right to review and update our policies periodically.
Medical Card System, Inc.
All Rights Reserved®
4
Clinical Medical Policy Department
Clinical Affairs Division
12. Medscape. Matthew R Cooperberg, MD, MPH; Chief Editor: Edward David Kim, MD, FACS.
Cryotherapy in Prostate Cancer. Updated: March 08, 2012. Accessed August 20, 2014. Available
at URL Address: http://emedicine.medscape.com/article/458187-overview#aw2aab6b2b3
POLICY HISTORY
DATE
December 22, 2007
ACTION
Origination of Policy
August 11, 2009
August 25, 2010
August 18,2011
July 12, 2012
December 10, 2012
Yearly Review
Yearly Review
Yearly Review
Yearly Review
Review
August 19, 2013
February 21,2014
Yearly Review
Revised
August 20, 2014
Yearly Review
COMMENT
Deleted ICD-9 Codes from the policy: 198.82
References updated
References updated.
Policy was reviewed and approved by the Medical Card System (MCS)
Medical Advisory Committee (MAC) on December 10, 2012.
References updated.
To the Coding section: A new ICD-10 Codes (Preview Draft) section was
added to the policy.
References updated.
To the Contraindication/Limitations Section:
 Contraindication/Limitation #2 was modified.
 New contraindication #8 was added to the Policy.
To the Coding Section: HCPCS code C2618 was reviewed to add a word in
the description.
To the References Section: New Reference #12 was added to the Policy.
This document is for informational purposes only. It is not an authorization, certification, explanation of benefits, or contract. Receipt of
benefits is subject to satisfaction of all terms and conditions of coverage. Eligibility and benefit coverage are determined in accordance with
the terms of the member’s plan in effect as of the date services are rendered. Medical Card System, Inc., (MCS) medical policies are
developed with the assistance of medical professionals and are based upon a review of published and unpublished information including, but
not limited to, current medical literature, guidelines published by public health and health research agencies, and community medical
practices in the treatment and diagnosis of disease. Because medical practice, information, and technology are constantly changing, Medical
Card System, Inc., (MCS) reserves the right to review and update its medical policies at its discretion. Medical Card System, Inc., (MCS)
medical policies are intended to serve as a resource to the plan. They are not intended to limit the plan’s ability to interpret plan language as
deemed appropriate. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type,
quality, and levels of care and treatment they choose to provide.
This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract.
Medical technology is constantly changing and we reserves the right to review and update our policies periodically.
Medical Card System, Inc.
All Rights Reserved®
5