LCD/NCD Portal

L28811

 

CRYOSURGICAL ABLATION OF THE PROSTATE

 

 

01/01/2010

 

 

Indications and Limitations of Coverage and/or Medical Necessity

• 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:

o 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:

o Have failed a trial of radiation therapy as their primary treatment.

And

o 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.

 

 

13x Hospital Outpatient

85x 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.

 

0360 Operating Room Services - General Classification

0361 Operating Room Services - Minor Surgery

0362 Operating Room Services - Organ Transplant - Other than Kidney

0367 Operating Room Services - Kidney Transplant

0369 Operating Room Services - Other OR Services

 

 

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

 

 

Documentation 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.

Treatment Logic

• 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.

 

 

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.

 

FCSO LCD 28811, Cryosurgical Ablation of the Prostate, 01/01/2010. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

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.

 

 

AMA CPT Copyright Statement

CPT codes, descriptions and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

 

 

CMS LCD CRYOSURGICAL ABLATION OF THE PROSTATE