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DESCRIPTIONCryoablation is one of several methods available to treat clinically localized prostate cancer, and may be considered an alternative to radical prostatectomy or radiation therapy. It also may be used for salvage of non-metastatic relapse following initial therapy for clinically localized disease. Using percutaneously inserted cryoprobes, the glandular tissue is rapidly frozen and thawed such that tissue necrosis follows. Hypothesized advantages of cryosurgical ablation include that the procedure may be less invasive than surgery and recovery time may be shorter. While external-beam radiation therapy requires multiple treatments, typically only one (1) treatment is required for cryoablation.
Subtotal prostate cryoablation is also being evaluated as a form of more localized therapy (referred to by some as “male lumpectomy”) for small localized prostate cancers.
POLICYCryoablation of the prostate may be considered medically necessary as treatment of clinically localized (organ-confined) prostate cancer when performed
Subtotal prostate cryoablation is considered investigational in the treatment of prostate cancer.
POLICY GUIDELINESInvestigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Members specific benefit plan language.
POLICY HISTORY8/1999: Approved by Medical Policy Advisory Committee (MPAC)
9/21/2001: Policy exception deleted - For Federal Employee Program (FEP) subscribers only, cryosurgery is considered medically necessary only as a primary treatment for localized prostate cancer (cryosurgical ablation of the prostate). It is considered investigational as a treatment of last resort for prostate cancer, salvage therapy, local failures after radical prostatectomy, external beam irradiation and brachytherapy (Reference Document # 99-54IHR). - Blue Cross Blue Shield Association policy # 7.01.79 considers investigational effective 08/15/01
10/11/2001: Policy exception added
2/8/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
5/2002: Reviewed by MPAC; investigational status changed to medically necessary, Sources updated
9/20/2002: Code Reference section updated
9/5/2003: ICD-9 198.82 added, HCPCS G0160 deleted
1/30/2007: Policy reviewed, returned to investigational status to align with BCBSA policy. Covered codes moved to non-covered. ICD-9 codes 185, 198.82, and 233.4 removed. FEP policy exceptions deleted.
5/16/2007: Policy reviewed, no changes. Policy name changed to "Cryoablation of Clinically Localized Prostate Cancer." Formerly named "Cryosurgery for Prostatic Carcinoma"
6/5/2009: Policy statement section updated to include medically necessary indications for localized (organ-confined) prostate cancer as initial treatment and salvage treatment. Coding section updated: CPT code 55873 moved from non-covered to covered, ICD-9 procedure code 60.62 moved from non-covered to covered. ICD-9 diagnosis codes 185, 198.82, 233.4, V10.46 added to policy.
3/15/2010: Code Reference section updated. Description for CPT code 55873 revised 1-1-2010.
07/29/2011: Deleted "Clinically Localized" from the policy title to align with scope of policy statement. Deleted outdated references from the Sources section.
07/13/2012: Policy reviewed; no changes.
08/14/2013: Policy reviewed; no changes.
SOURCE(S)Blue Cross Blue Shield Association policy # 7.01.79
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.