Prostate Disease: Diagnosis, Staging, and Treatment

Policy ID: S-275-007

Section: Surgery

Effective Date: May 02, 2022

Revised Date: June 14, 2024

Revision Effective Date: September 02, 2024

Last Reviewed: July 16, 2024

Applies To: Commercial and Medicaid Expansion

Description

Diagnosing and Staging of Prostate Cancer

Saturation biopsy, either initial or repeat, for a high-risk individual provides pathologists with an extensive selection of cells to test and can be used to help diagnose and stage prostate cancer when previous conventional prostate biopsies have been negative.

Treatment of Benign Prostate Hypertrophy or Prostate Cancer

A wide variety of minimally invasive therapies and surgery are available for diseases of the prostate and may include but are not limited to:

Cryoablation of the prostate; or
Cystourethroscopy with insertion of permanent adjustable transprostatic implant; or
Holmium laser:
- Ablation of the prostate [HoLAP]; or
- Enucleation of the prostate [HoLEP]; or
- Resection of the prostate [HoLRP]; or
Photoselective laser vaporization (PVP); or
Prostatic stents; or
Prostatic urethral lift (PUL); or
Radical prostatectomy; or
Simple prostatectomy; or
Transuretheral anterior prostate commissurotomy; or
Transurethral electrovaporization of the prostate (TUEVP, TUVAP or TUEVAP); or
Transuretheral incision of the prostate (TUIP); or
Transurethral microwave thermotherapy (TUMT); or
Transurethral resection of the prostate (TURP); or
Transuretheral waterjet ablation of the prostate; or
Transurethral ultrasound-guided laser-induced prostatectomy (TULIP); or
Water-induced thermotherapy (WIT), also called thermourethral hot-water therapy; or
Water vapor thermal therapy when prostate volume is less than 80 grams.

Polyethylene glycol (PEG) hydrogel is a slowly resorbing hydrogel injected into Denonvillier's space to limit rectal toxicity before radiation therapy for prostate cancer.

Note: Oral pharmacological treatments and prostate specific antigen testing are not addressed in this policy.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date; or

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

*See below to determine whether the policy rules apply to initial and adjustment claims based on date of processing (DOP) or Date of Service (DOS).

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Diagnosis and Staging: Prostate Cancer

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Saturation biopsy of the prostate (taking 20 or more core tissue samples at one time) may be considered medically necessary for ANY of the following indications in individuals with two (2) prior extended transrectal prostate biopsies (up to 12 core tissue samples) negative for invasive cancer:

Individuals with an elevated prostate specific antigen (PSA) that is persistently rising; or
Individuals with histologic evidence of atypia on prior prostate biopsy; or
Individuals with histologic findings of high-grade prostatic intraepithelial neoplasia (PIN) on prior biopsy.

Saturation needle biopsy of the prostate not meeting the criteria as indicated in this policy is considered experimental/investigational and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

0443T

55700

55706

Treatment of the Prostate: Benign Prostate Hypertrophy, Prostate Cancer

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

The surgical and minimally invasive treatment of urinary outlet obstruction due to BPH may be considered medically necessary when ALL the following criteria are met:

The individual has a diagnosis of lower urinary tract symptoms (LUTS) secondary to BPH that interfere with activities of daily living; and
The individual has a peak urine flow rate (Qmax) less than 15 cc/sec on a voided volume that is greater than 125 cc; and
The individual has failed a trial of satisfactory voiding with medication (alpha blocker and/or alpha-reductase inhibitor) or intolerance to medication (alpha blocker and/or 5-alpha-reductase inhibitor).

The surgical and minimally invasive treatment of urinary outlet obstruction due to prostate cancer may be considered medically necessary when ONE the following criteria are met:

The individual has a diagnosis or history of prostate cancer and is not a candidate for surgical resection of the prostate but will be treated by radiation therapy and has symptoms that are so severe that immediate relief is required; or
The individual has a diagnosis or history of prostate cancer and is clinically in remission as evidenced by a prostate specific antigen (PSA) less than 1.0 ng/mL.

The use of any treatments/procedures not meeting the criteria as indicated in this policy are considered not medically necessary.

Procedure Codes

0421T

0582T

0619T

52282

52441

52442

52450

52601

52630

52640

52647

52648

52649

53850

53852

53854

55821

55831

Prostatectomy

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

A simple or radical prostatectomy may be considered medically necessary for individuals with a diagnosis of localized prostate cancer.

A simple or radical prostatectomy not meeting the criteria as indicated in this policy is considered not medically necessary

Procedure Codes

55801

55810

55812

55815

55840

55842

55845

55866

55867

Prostatic Urethral Lift (PUL)

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

PUL in individuals 45 years of age or older with moderate-to-severe lower urinary tract obstruction due to BPH may be considered medically necessary when ALL the following criteria are met:

Persistent or progressive lower urinary tract symptoms despite medical therapy (1-adrenergic antagonists maximally titrated, 5-reductase inhibitors, or combination medication therapy maximally titrated) over a trial period of four (4) -12 weeks or is unable to tolerate medical therapy; and
Prostate gland volume is less than or equal to 100 mL; and
Prostate anatomy demonstrates normal bladder neck without an obstructive or protruding median lobe; and
Individual does not have an active urinary tract infection, or recent prostatitis within past year the last 12 months; and
Individual has had appropriate testing to exclude diagnosis of prostate cancer; and
Individual does not have a known allergy to nickel, titanium, or stainless steel.

PUL not meeting the criteria indicated in this policy is considered not medically necessary.

Procedure Codes

52441

52442

Cryoablation

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Whole gland cryoablation of the prostate gland as treatment of clinically localized (organ-confined) prostate cancer may be considered medically necessary when performed:

As initial treatment; or
As salvage treatment of disease that recurs following radiotherapy.

Whole gland cryosurgical ablation of the prostate gland not meeting the criteria as indicated in this policy is considered not medically necessary.

Subtotal prostate cryoablation for the treatment of prostate cancer is considered E/I experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Code

55873

High-Intensity Focused Ultrasound (HIFU)

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Whole gland HIFU may be considered medically necessary as a local treatment for recurrent prostate cancer following radiation therapy when individual meets ALL the following criteria:

Original clinical stage (Please see staging tables below):
- T _{1 -} T _2;and
- NX or NO; and
Life expectancy of greater than 10 years; and
PSA of less than 10 ng/mL; and
Positive post-RT transrectal (TRUS) biopsy; and
No evidence of metastatic disease.

HIFU not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

55880

55899

Polyethylene-glycol Hydrogel (PEG)

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

PEG hydrogel may be considered medically necessary in individuals diagnosed with prostate cancer and are going to be treated with radiotherapy.

PEG hydrogel usage not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Code

55874

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

The use of ANY focal therapy modality, including but not limited to the following procedures, for individuals with localized prostate cancer is considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature:

Radiofrequency ablation; or
Photodynamic therapy; or
Transperineal focal laser ablation.

Procedure Codes

0655T

0738T

0739T

0867T

55899

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

The following procedures/treatments for BPH, including but not limited to the following procedures, are considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature:

HIFU ablation for the treatment for BPH; or
Placement of temporary prostatic stents for the treatment for BPH; or
Focal laser ablation; or
Transperineal laser ablation for the treatment of BPH

Procedure Codes

0714T

53855

53899

55873

55880

55899

Outpatient HCPCS (C Codes)

C2596

C9739

C9740

C9769

Tumor (T) Staging

T ₁

The tumor is too small to be seen on scans or felt during examination of the prostate (it has been discovered by needle biopsy).

T ₂

The tumor is completely inside the prostate gland.

T ₃

The tumor has broken through the capsule of the prostate gland.

T ₄

The tumor has spread into other body organs.

Lymph Node (N) Staging

No cancer cells found in any lymph nodes

One positive lymph node smaller than 2 cm across.

More than 1 positive lymph node; or one that is between 2cm and 5 cm across.

Any positive lymph node that is bigger than 5 cm across.

Lymph nodes cannot be assessed

Diagnosis Codes

Covered diagnosis codes for procedure codes: 0421T, 0582T, 52441, 52442, 52450, 52601, 52630, 52640, 52647, 52648, 52649, 53850, 53852, 53854, 55801, 55810, 55812, 55815, 55821, 55831, 55840, 55842, 55845, 55866 and 55867

D29.1

D40.0

D49.59

N32.0

N32.42

N32.89

N32.9

N39.41

N39.42

N39.43

N39.44

N39.45

N39.46

N40.0

N40.1

N40.2

N40.3

N41.0

N41.1

N41.2

N41.3

N41.4

N41.8

N41.9

N42.31

N42.83

N42.89

N42.9

R97.20

R97.21

Covered diagnosis codes for procedure codes: 0582T, 52441, 52442, 52601, 52630, 52640, 52647, 52648, 52649, 53850, 53852, 55866, 55873, and 55880

C61

C79.82

D07.5

Covered diagnosis codes for procedure codes: 0443T, 55700, 55706, 55810, 55812, 55815, 55840, 55842, 55845, 55866, and 55874

C61

C79.82

D07.5

D40.0

Covered diagnosis codes for procedure code: 0619T

N40.0

N40.1

Professional Statements and Societal Positions Guidelines

National Comprehensive Cancer Network (NCCN) -2024

Saturation Biopsy

Current NCCN Prostate Cancer guidelines (v.4.2024) do not mention saturation biopsy. The guideline mentions prostate cancer is identified by risk group as follows:

Risk Group

Recommendation

Very Low Risk Group

Has All of the following:

• cT1c

• Grade Group one (1)

• PSA less than (<)10 ng/mL

• Less than (<) three (3) prostate biopsy fragments/cores positive, Less than or equal to (≤)50 percent cancer in each fragment/corek

• PSA density less than (<)0.15 ng/mL/g

Low Risk Group

Has All of the following but does not qualify for very low risk:

cT1-cT2a
Grade Group one (1)
PSA less than (<)10 ng/mL

Intermediate Risk Group

Has All of the following:

No high-risk group features
No very-high-risk group features
Has one or more intermediate risk factors (IRFs):
- cT2b-cT2c
- Grade Group two (2) or three (3)
PSA 10-20 ng/mL

Favorable intermediate

Has All of the following:

One (1) IRF
Grade Group one (1) or two (2)
Less than (<)50% biopsy cores positive (e.g., less than (<) six (6) of 12 cores)

Unfavorable intermediate

Has One (1) or more of the following:

Two (2) or three (3) IRFs
Grade Group three (3)
Greater than or equal to (≥) 50 percent biopsy cores positive (e.g., greater than or equal to (≥) six (6) of 12 cores)

High

Has no very-high-risk features and has exactly One (1) high-risk feature:

cT3a; or
Grade Group four (4) or five (5); or
PSA greater than (>)20 ng/mL

Very High

Has at least one (1) of the following:

• cT3b-cT4

• Primary Gleason pattern five (5)

• Two (2) or three (3) high-risk features

• Greater than (>) four (4) cores with Grade Group four (4) or five (5)

Cryosurgery/HIFU

Current NCCN Prostate guidelines (v.3.2022) recommends only cryosurgery and high-intensity focused ultrasound as local therapy options for RT recurrence in the absence of metastatic disease.

Polyethylene-glycol Hydrogel (PEG)

Current NCCN Prostate guidelines (v.3.2022) state, 'Overall, the panel believes that biocompatible and biodegradable perirectal spacer materials may be implanted between the prostate and rectum in individuals undergoing external radiotherapy with organ-confined prostate cancer in order to displace the rectum from high radiation dose regions.'

American Urological Association (AUA) - 2021

The AUA guidelines (2021) address surgical interventions for BPH/LUTS as follows:

Surgery is recommended for individuals who have renal insufficiency secondary to BPH, refractory urinary retention secondary to BPH, recurrent urinary tract infections (UTIs), recurrent bladder stones or gross hematuria due to BPH, and/or with LUTS/BPH refractory to or unwilling to use other therapies.
Clinicians should inform individuals of the possibility of treatment failure and the need for additional or secondary treatments when considering surgical and minimally invasive treatments for LUTS/BPH.

Procedure/Individual Population

Recommendation

Laser Enucleation

Holmium laser enucleation of the prostate (HoLEP) or thulium laser enucleation of the prostate (ThuLEP) should be considered as an option, depending on the clinician's expertise with these techniques, as prostate size-independent options for the treatment of LUTS/BPH.

Medically Complicated Individuals

HoLEP, PVP, and ThuLEP should be considered as treatment options in individuals who are at higher risk of bleeding.

PUL

PUL should be considered as a treatment option for individuals with LUTS/BPH provided prostate volume 30-80cc and verified absence of an obstructive middle lobe.

PUL may be offered as a treatment option to eligible individuals who desire preservation of erectile and ejaculatory function

PVP

PVP should be offered as an option using 120W or 180W platforms for the treatment of LUTS/BPH.

Robotic Waterjet Treatment

Robotic waterjet treatment (RWT) may be offered as a treatment option to individuals with LUTS/BPH provided prostate volume 30-80cc.

Simple Prostatectomy

Open, laparoscopic, or robotic assisted prostatectomy should be considered as treatment options by clinicians, depending on their expertise with these techniques, only in individuals with large to very large prostates.

TURP

TURP should be offered as a treatment option for individuals with LUTS/BPH.

TUIP

TUIP should be offered as an option for individuals with prostates 30cc for the surgical treatment of LUTS/BPH.

TUMT

TUMT may be offered as a treatment option to individuals with LUTS/BPH.

TUNA

TUNA is not recommended for the treatment of LUTS/BPH.

TUVP

Bipolar TUVP may be offered as an option to individuals for the treatment of LUTS/BPH.

WVTT

WVTT should be considered as a treatment option for individuals with LUTS/BPH provided prostate volume 30-80cc.

WVTT may be offered as a treatment option to eligible individuals who desire preservation of erectile and ejaculatory function.

ND Committee Review

Internal Medical Policy Committee 3-23-2022 New policy for North Dakota

Internal Medical Policy Committee 7-21-2022 Coding update - Effective July 01, 2022

Added Procedure code 0714T

Internal Medical Policy Committee 11-29-2022 Revision with coding update

Coding Update - Effective January 01, 2023
- Added procedure code 0738T, 0739T and 55867
Revision - Effective January 02, 2023
- Updated language

Internal Medical Policy Committee 11-15-2023 - Revision - Effective January 01, 2024

Removed bullet point regarding Prostatic Arterial Embolization
Removed procedure code 37243

Internal Medical Policy Committee 7-16-2024 - Coding and Revision updates

Coding update - Effective July 01, 2024
- Added Procedure Code 0867T; and
- Added Policy Application; and
Revision with coding update - Effective September 02, 2024
- Added Covered diagnosis codes N42.31; N42.32; R97.20 and R97.21; and
- Added bullet Transperineal laser ablation for the treatment of BPH; and
- Updated Professional Statements and Societal Positions Guidelines.

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: S-275-006

Section: Surgery

Effective Date: May 02, 2022

Revised Date: June 04, 2024

Revision Effective Date: July 01, 2024

Last Reviewed: July 16, 2024

Archived Date: September 01, 2024

Applies To: Commercial and Medicaid Expansion

Description

Diagnosing and Staging of Prostate Cancer

Treatment of Benign Prostate Hypertrophy or Prostate Cancer

A wide variety of minimally invasive therapies and surgery are available for diseases of the prostate and may include but are not limited to:

Cryoablation of the prostate; or
Cystourethroscopy with insertion of permanent adjustable transprostatic implant; or
Holmium laser:
- Ablation of the prostate [HoLAP]; or
- Enucleation of the prostate [HoLEP]; or
- Resection of the prostate [HoLRP]; or
Photoselective laser vaporization (PVP); or
Prostatic stents; or
Prostatic urethral lift (PUL); or
Radical prostatectomy; or
Simple prostatectomy; or
Transuretheral anterior prostate commissurotomy; or
Transurethral electrovaporization of the prostate (TUEVP, TUVAP or TUEVAP); or
Transuretheral incision of the prostate (TUIP); or
Transurethral microwave thermotherapy (TUMT); or
Transurethral resection of the prostate (TURP); or
Transuretheral waterjet ablation of the prostate; or
Transurethral ultrasound-guided laser-induced prostatectomy (TULIP); or
Water-induced thermotherapy (WIT), also called thermourethral hot-water therapy; or
Water vapor thermal therapy when prostate volume is less than 80 grams.

Polyethylene glycol (PEG) hydrogel is a slowly resorbing hydrogel injected into Denonvillier's space to limit rectal toxicity before radiation therapy for prostate cancer.

Note: Oral pharmacological treatments and prostate specific antigen testing are not addressed in this policy.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

*See below to determine whether the policy rules apply to initial and adjustment claims based on date of processing (DOP) or Date of Service (DOS).

Criteria

Diagnosis and Staging: Prostate Cancer

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Individuals with an elevated prostate specific antigen (PSA) that is persistently rising; or
Individuals with histologic evidence of atypia on prior prostate biopsy; or
Individuals with histologic findings of high-grade prostatic intraepithelial neoplasia (PIN) on prior biopsy.

Procedure Codes

0443T

55700

55706

Treatment of the Prostate: Benign Prostate Hypertrophy, Prostate Cancer

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

The surgical and minimally invasive treatment of urinary outlet obstruction due to BPH may be considered medically necessary when ALL the following criteria are met:

The individual has a diagnosis of lower urinary tract symptoms (LUTS) secondary to BPH that interfere with activities of daily living; and
The individual has a peak urine flow rate (Qmax) less than 15 cc/sec on a voided volume that is greater than 125 cc; and
The individual has failed a trial of satisfactory voiding with medication (alpha blocker and/or alpha-reductase inhibitor) or intolerance to medication (alpha blocker and/or 5-alpha-reductase inhibitor).

The surgical and minimally invasive treatment of urinary outlet obstruction due to prostate cancer may be considered medically necessary when ONE the following criteria are met:

The individual has a diagnosis or history of prostate cancer and is not a candidate for surgical resection of the prostate but will be treated by radiation therapy and has symptoms that are so severe that immediate relief is required; or
The individual has a diagnosis or history of prostate cancer and is clinically in remission as evidenced by a prostate specific antigen (PSA) less than 1.0 ng/mL.

The use of any treatments/procedures not meeting the criteria as indicated in this policy are considered not medically necessary.

Procedure Codes

0421T

0582T

0619T

52282

52441

52442

52450

52601

52630

52640

52647

52648

52649

53850

53852

53854

55821

55831

Prostatectomy

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

A simple or radical prostatectomy may be considered medically necessary for individuals with a diagnosis of localized prostate cancer.

A simple or radical prostatectomy not meeting the criteria as indicated in this policy is considered not medically necessary

Procedure Codes

55801

55810

55812

55815

55840

55842

55845

55866

55867

Prostatic Urethral Lift (PUL)

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

PUL in individuals 45 years of age or older with moderate-to-severe lower urinary tract obstruction due to BPH may be considered medically necessary when ALL the following criteria are met:

Persistent or progressive lower urinary tract symptoms despite medical therapy (1-adrenergic antagonists maximally titrated, 5-reductase inhibitors, or combination medication therapy maximally titrated) over a trial period of four (4) -12 weeks or is unable to tolerate medical therapy; and
Prostate gland volume is less than or equal to 100 mL; and
Prostate anatomy demonstrates normal bladder neck without an obstructive or protruding median lobe; and
Individual does not have an active urinary tract infection, or recent prostatitis within past year the last 12 months; and
Individual has had appropriate testing to exclude diagnosis of prostate cancer; and
Individual does not have a known allergy to nickel, titanium, or stainless steel.

PUL not meeting the criteria indicated in this policy is considered not medically necessary.

Procedure Codes

52441

52442

Cryoablation

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Whole gland cryoablation of the prostate gland as treatment of clinically localized (organ-confined) prostate cancer may be considered medically necessary when performed:

As initial treatment; or
As salvage treatment of disease that recurs following radiotherapy.

Whole gland cryosurgical ablation of the prostate gland not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Code

55873

High-Intensity Focused Ultrasound (HIFU)

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Whole gland HIFU may be considered medically necessary as a local treatment for recurrent prostate cancer following radiation therapy when individual meets ALL the following criteria:

Original clinical stage (Please see staging tables below):
- T _{1 -} T _2;and
- NX or NO; and
Life expectancy of greater than 10 years; and
PSA of less than 10 ng/mL; and
Positive post-RT transrectal (TRUS) biopsy; and
No evidence of metastatic disease.

Procedure Codes

55880

55899

Polyethylene-glycol Hydrogel (PEG)

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

PEG hydrogel may be considered medically necessary in individuals diagnosed with prostate cancer and are going to be treated with radiotherapy.

Procedure Code

55874

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Radiofrequency ablation; or
Photodynamic therapy; or
Transperineal focal laser ablation.

Procedure Codes

0655T

0714T

0738T

0739T

0867T

55899

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

HIFU ablation for the treatment for BPH; or
Placement of temporary prostatic stents for the treatment for BPH; or
Focal laser ablation.

Procedure Codes

53855

53899

55873

55880

55899

Outpatient HCPCS (C Codes)

C2596

C9739

C9740

C9769

Tumor (T) Staging

T ₁

The tumor is too small to be seen on scans or felt during examination of the prostate (it has been discovered by needle biopsy).

T ₂

The tumor is completely inside the prostate gland.

T ₃

The tumor has broken through the capsule of the prostate gland.

T ₄

The tumor has spread into other body organs.

Lymph Node (N) Staging

No cancer cells found in any lymph nodes

One positive lymph node smaller than 2 cm across.

More than 1 positive lymph node; or one that is between 2cm and 5 cm across.

Any positive lymph node that is bigger than 5 cm across.

Lymph nodes cannot be assessed

Diagnosis Codes

D29.1

D40.0

D49.59

N32.0

N32.89

N32.9

N39.41

N39.42

N39.43

N39.44

N39.45

N39.46

N40.0

N40.1

N40.2

N40.3

N41.0

N41.1

N41.2

N41.3

N41.4

N41.8

N41.9

N42.83

N42.89

N42.9

Covered diagnosis codes for procedure codes: 0582T, 52441, 52442, 52601, 52630, 52640, 52647, 52648, 52649, 53850, 53852, 55866, 55873, and 55880

C61

C79.82

D07.5

Covered diagnosis codes for procedure codes: 0443T, 55700, 55706, 55810, 55812, 55815, 55840, 55842, 55845, 55866, and 55874

C61

C79.82

D07.5

D40.0

Covered diagnosis codes for procedure code: 0619T

N40.0

N40.1

Professional Statements and Societal Positions Guidelines

National Comprehensive Cancer Network (NCCN) -2022

Saturation Biopsy

Current NCCN Prostate Cancer guidelines (v.3.2022) do not mention saturation biopsy. The guideline mentions biopsy identified by risk group as follows:

Risk Group

Recommendation

Very Low Risk Group

Consider confirmatory mp MRI prostate biopsy if MRI not performed initially. All individuals should undergo a confirmatory prostate biopsy within 1-2 years of their diagnostic biopsy.

Low Risk Group

Consider confirmatory mp MRI prostate biopsy and/or molecular tumor analysis if MRI not performed initially to establish candidacy for active surveillance. All individuals should undergo a confirmatory prostate biopsy within 1-2 years of their diagnostic biopsy.

Intermediate Risk Group

Consider confirmatory mp MRI prostate biopsy and/or molecular tumor analysis if MRI not performed initially for those considering active surveillance. All individuals should undergo a confirmatory prostate biopsy within 1-2 years of their diagnostic biopsy.

Active Surveillance

Consider confirmatory mp MRI prostate biopsy and/or molecular tumor analysis if MRI not performed initially. All individuals should undergo a confirmatory prostate biopsy within 1-2 years of their diagnostic biopsy.

Cryosurgery/HIFU

Current NCCN Prostate guidelines (v.3.2022) recommends only cryosurgery and high-intensity focused ultrasound as local therapy options for RT recurrence in the absence of metastatic disease.

Polyethylene-glycol Hydrogel (PEG)

American Urological Association (AUA) - 2021

The AUA guidelines (2021) address surgical interventions for BPH/LUTS as follows:

Surgery is recommended for individuals who have renal insufficiency secondary to BPH, refractory urinary retention secondary to BPH, recurrent urinary tract infections (UTIs), recurrent bladder stones or gross hematuria due to BPH, and/or with LUTS/BPH refractory to or unwilling to use other therapies.
Clinicians should inform individuals of the possibility of treatment failure and the need for additional or secondary treatments when considering surgical and minimally invasive treatments for LUTS/BPH.

Procedure/Individual Population

Recommendation

Laser Enucleation

Medically Complicated Individuals

HoLEP, PVP, and ThuLEP should be considered as treatment options in individuals who are at higher risk of bleeding.

PUL

PUL should be considered as a treatment option for individuals with LUTS/BPH provided prostate volume 30-80cc and verified absence of an obstructive middle lobe.

PUL may be offered as a treatment option to eligible individuals who desire preservation of erectile and ejaculatory function

PVP

PVP should be offered as an option using 120W or 180W platforms for the treatment of LUTS/BPH.

Robotic Waterjet Treatment

Robotic waterjet treatment (RWT) may be offered as a treatment option to individuals with LUTS/BPH provided prostate volume 30-80cc.

Simple Prostatectomy

TURP

TURP should be offered as a treatment option for individuals with LUTS/BPH.

TUIP

TUIP should be offered as an option for individuals with prostates 30cc for the surgical treatment of LUTS/BPH.

TUMT

TUMT may be offered as a treatment option to individuals with LUTS/BPH.

TUNA

TUNA is not recommended for the treatment of LUTS/BPH.

TUVP

Bipolar TUVP may be offered as an option to individuals for the treatment of LUTS/BPH.

WVTT

WVTT should be considered as a treatment option for individuals with LUTS/BPH provided prostate volume 30-80cc.

WVTT may be offered as a treatment option to eligible individuals who desire preservation of erectile and ejaculatory function.

ND Committee Review

Internal Medical Policy Committee 3-23-2022 New policy for North Dakota

Internal Medical Policy Committee 7-21-2022 Coding update - Effective July 01, 2022

Added Procedure code 0714T

Internal Medical Policy Committee 11-29-2022 Revision with coding update
• Coding Update - Effective January 01, 2023
o Added procedure code 0738T, 0739T and 55867
• Revision - Effective January 02, 2023
o Updated language

Internal Medical Policy Committee 11-15-2023 - Revision - Effective January 01, 2024

Removed bullet point regarding Prostatic Arterial Embolization
Removed procedure code 37243

Internal Medical Policy Committee 7-16-2024 - Coding - Effective July 01, 2024

Added Procedure Code 0867T
Added Policy Application

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Prostate Disease: Diagnosis, Staging, and Treatment

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National Comprehensive Cancer Network (NCCN) -2024

Saturation Biopsy

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