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Medical Policy: 07.01.07
Original Effective Date: November 1995
Reviewed: June 2007
Revised: April 2006
This policy applies to all products unless specific contract
limitations, exclusions or exceptions apply. Please refer to the member's coverage
manual for benefit availability. Managed care guidelines related to referral authorization,
and precertification of inpatient hospitalization, home health, home infusion and
hospice services apply.
Description:
Cryoablation is a minimally-invasive surgical technique that involves controlled freezing of the prostate gland in order to destroy cancer cells. During cryoablation of the prostate, the surrounding stroma and capillaries are damaged and subsequently have an inadequate blood supply that is believed to slow the growth of cancer.
Policy:
Cryoablation may be considered medically necessary as primary treatment for clinically localized prostate cancer (stages T1-T3) and as salvage treatment for recurrent prostate cancer following external beam irradiation.
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Procedure Codes and Billing
Guidelines:
- To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- CPT code 55873 cryosurgical ablation of the prostate (includes ultrasonic guidance for interstitial cryosurgical probe placement).
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Selected References:
- A review of the medical literature and recommendations from Wellmark’s Medical Policy Advisory Council (MPAC), a council of practicing physicians who advise and assist Wellmark in the development and implementation of medical policies. The council is comprised of primary care and specialty physicians from Iowa and South Dakota.
- The Medical Policy Reference Manual developed by the Blue Cross Blue Shield Association Health Management Systems, based on Technology Evaluation Center (TEC) criteria.
- Da la Taille, A, Katz, A. Cryosurgery: is it an effective option for patients failing radiation? Current Opinion in Urology 2000, 10:409-413.
- Benoit, RM, Cohen, JK, Miller, Jr, RJ. Counseling patients about cryotherapy for prostate cancer in the information age. Seminars in Urologic Oncology, Vol. 18, Number 3 (August), 2000: pp226-232.
- Beerlage, HP, Thuroff, S, Madersbacher, St., Zlotta, AR, Aus, G, de Reijke, Th.M, de la Rosette, JJMCH. Current status of minimally invasive treatment options for localized prostate carcinoma. European Urology 2000; 37:2-13.
- Bahn DK, Lee F, Badalament R, Kumar A, Greski J, Chernick M. Targeted cryoablation of the prostate: 7-year outcomes in the primary treatment of prostate cancer. Urology. 2002 Aug;60(2 Suppl 1):3-11.
- Donnelly BJ, Saliken JC, Ernst DS, Ali-Ridha N, Brasher PM, Robinson JW, Rewcastle JC. Prospective trial of cryosurgical ablation of the prostate: five-year results. Urology. 2002 Oct;60(4):645-9
- Prepelica KL, Okeke Z, Murphy A, Katz AE. Cryosurgical ablation of the prostate. Cancer. 2005 Mar 3. Abstract retrieved March 23, 2005 from PubMed database.
- Prepelica KL, Okeke Z, et al. Cryosurgical ablation of the prostate: high risk patient outcomes. Cancer. 2005 Apr. 15;103(8):1625-30.
- Link BA. Recent trends in surgical management of localized prostate cancer. Clinical Prostate Cancer. 2005 Sep;4(2):130-3.
- Ball AJ, Gambill B, et al. Prospective longitudinal comparative study of early health-related quality-of-life outcomes in patients undergoing surgical treatment for localized prostate cancer: a short-term evaluation of five approaches from a single institution. J Endourol. 2006 Oct;20(10):723-31.
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New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:
Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave
Des Moines, Iowa 50309
*Current Procedural Terminology © 2008 American Medical Association. All Rights Reserved.
Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
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