Conditions related to the prostate gland include, but are not limited to:
The surgical and minimally invasive treatment of urinary outlet obstruction due to benign prostatic hyperplasia (BPH) may be considered medically necessary when ALL of the following criteria are met:
The surgical and minimally invasive treatment of urinary outlet obstruction when using one of the procedures above may be considered medically necessary when the individual has a diagnosis or history of prostate cancer and meets ONE of the following criteria:
A radical prostatectomy may be considered medically necessary for individuals with a diagnosis of localized prostate cancer.
The use of any of the procedures listed above for any other indication is considered not medically necessary.
52441 |
52442 |
52450 |
52601 |
52630 |
52640 |
52647 |
52648 |
52649 |
53850 |
53852 |
53854 |
55801 |
55810 |
55812 |
55815 |
55821 |
55831 |
55840 |
55842 |
55845 |
55866 |
|
|
|
|
|
|
Whole gland cryosurgical ablation of the prostate gland as treatment of clinically localized (organ confined) prostate cancer may be considered medically necessary when performed:
The use of cryosurgical ablation of the prostate gland for any other indication is considered not medically necessary.
55873 |
|
|
|
|
|
|
The use of any focal therapy modality treatment for individuals with localized prostate cancer is considered experimental/investigational (E/I) and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature. Examples of focal Modalities include,but are not limited to, the following:
55899 |
|
|
|
|
|
|
The following procedures/treatments for BPH are considered E/I and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature:
Subtotal prostate cryoablation for the treatment of prostate cancer is considered E/I and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
37243 |
53855 |
53899 |
55873 |
55899 |
|
|
C9739 |
C9740 |
C9747 |
C9769 |
|
|
|
Covered diagnosis codes for procedure codes: 52441, 52442, 52450, 52601, 52630, 52640, 52647, 52648, 52649, 53850, 53852, 53854, 55801, 55810, 55812, 55815, 55821, 55831, 55840, 55842, 55845, 55866.
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: 52441, 52442, 52601, 52630, 52640, 52647, 52648, 52649, 53850, 53852, 55873, 55866
C61 |
C79.82 |
D07.5 |
Z85.46 |
|
|
|
Covered diagnosis codes for procedure codes: 55810, 55812, 55815, 55840, 55842, 55845 and 55866
C61 |
C79.82 |
D07.5 |
D40.0 |
|
|
|
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract, and subject to the applicable laws of your state.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you need these services, contact the Civil Rights Coordinator.
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.