L28811-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Cryosurgical Ablation of the Prostate (L28811)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09101

Contractor Type MAC - Part A

LCD Information

Document Information

LCD ID Number L28811

LCD Title Cryosurgical Ablation of the Prostate

Contractor's Determination Number A55873

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2011 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/16/2009

Original Determination Ending Date

Revision Effective Date

For services performed on or after 01/01/2010

Revision Ending Date

CMS National Coverage Policy

Coverage Issues Manual, Section 35-96 Medicare Hospital Manual, Section 425 Medicare Intermediary Manual, Section 3617

Program Memorandum 260 (Change Request 3168, dated 07/30/2004)

National Coverage Determinations Manual, Chapter 1, Section 230.9

Indications and Limitations of Coverage and/or Medical Necessity

Cryosurgery of the prostate gland, also known as cryosurgical ablation of the prostate (CSAP), destroys prostate tissue by applying extremely cold temperatures in order to reduce the size of the prostate gland.

CSAP can be carried out under general or spinal anesthesia and lasts approximately 2-3 hours. Five to six cryoprobes are placed transperinally under transrectal ultrasound (TRUS). Once the probes are in place, freezing is carried out while observing under TRUS the increasing echoes as the block of frozen prostate tissue approaches the rectal mucosa. Such monitoring minimizes the risk of rectal freezing. The possibility of injury to the urethra is decreased by the use of a warming device which is inserted into the urethra.

Effective for services performed on or after July 1, 1999, Medicare will consider cryosurgery of the prostate medically reasonable and necessary under the following circumstance:

• For primary treatment of patients with clinically localized, stages T1-T3, prostate cancer.

Effective for services performed on or after July 1, 2001, salvage cryosurgery of the prostate for recurrent cancer is medically necessary and appropriate only for those patients with localized disease who:

• Have failed a trial of radiation therapy as their primary treatment; and

• Meet one of the following conditions: Stage T2B or below, Gleason score <9, PSA <8ng/mL.

Note: Cryosurgery as salvage therapy is not covered under Medicare after failure of other therapies as the primary treatment.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

013x Hospital Outpatient 085x Critical Access Hospital

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

036X Operating Room Services - General Classification

CPT/HCPCS Codes

55873 CRYOSURGICAL ABLATION OF THE PROSTATE (INCLUDES ULTRASONIC GUIDANCE AND MONITORING)

ICD-9 Codes that Support Medical Necessity

185 MALIGNANT NEOPLASM OF PROSTATE

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

Medical record documentation maintained in the patient's file must demonstrate that the service was performed for the indications identified in this policy. In addition, documentation that the service was performed must be included in the patient's medical record. This information is normally found in the office/progress notes, hospital notes, and/or operative report.

Appendices

Utilization Guidelines N/A

Sources of Information and Basis for Decision

Benoit, R., Cohen, J., & Miller, R. (1998). Comparison of the hospital costs for radical prostatectomy and cryosurgical ablation of the prostate. Urology, 52, 820-824.

Chin, J., Downey, D., Mulligan, M., & Fenster, A. (1998). Three-dimensional transrectal ultrasound guided cryoablation for localized prostate cancer in nonsurgical candidates: a feasibility study and report of early results. Journal of Urology, 159, 910-914.

Long, J., Fallick, M., LaRock, D., & Rand, W. (1998). Preliminary outcomes following crysurgical ablation of the prostate in patients with clinically localized prostate carcinoma. The Journal of Urology, 159, 477-484.

Schmidt, J., Doyle, J., & Larison, S. (1998). Prostate cryoablation : update 1998. Ca Cancer J Clin, 48, 239-253.

Advisory Committee Meeting Notes This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation

with advisory groups, which includes representatives from numerous societies.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 01/01/2010

Revision History Number 1

Revision History Explanation Revision Number:1 Start Date of Comment Period:N/A

Start Date of Notice Period:01/01/2010 Revised Effective Date: 01/01/2010

LCR A2010-002

December 2009 Bulletin

Explanation of Revision: Annual 2010 HCPCS Update. Revised descriptor for CPT code 55873. The effective date of this revision is based on date of service.

Revision Number:Original

Start Date of Comment Period:N/A Start Date of Notice Period:12/04/2008

Revised Effective Date:02/16/2009

LCR A2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the fiscal intermediary predecessors of First Coast Service Options, Inc. (COSVI and FCSO).

For Florida (00090) this LCD (L28811) replaces LCD L1028 as the policy in notice. This document (L28811) is effective on 02/16/2009.

11/15/2009 - The description for CPT/HCPCS code 55873 was changed in group 1 8/1/2010 - The description for Bill Type Code 13 was changed

8/1/2010 - The description for Bill Type Code 85 was changed

8/1/2010 - The description for Revenue code 0360 was changed 8/1/2010 - The description for Revenue code 0361 was changed 8/1/2010 - The description for Revenue code 0362 was changed 8/1/2010 - The description for Revenue code 0367 was changed 8/1/2010 - The description for Revenue code 0369 was changed

Reason for Change HCPCS/ICD9 Descriptor Change