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Prostate cancer is a common cancer in men and is the second leading cause of cancer-related deaths in men in the US. The diagnosis of prostate cancer is made by biopsy of the prostate gland. The approach to biopsy has changed over time, especially with the advent of PSA (prostate-specific antigen) screening programs that identify cancer in prostates that are normal to palpation and to trans-rectal ultrasound. For patients with an elevated PSA-level but with a normal biopsy, questions exist about subsequent evaluation since repeat biopsy specimens may be positive for cancer in a substantial percentage of patients.

In the early 1990’s, use of sextant biopsies involving six random, evenly distributed biopsies became the standard approach to the diagnosis of prostate cancer. In the late 1990’s as studies showed high false-negative rates for this strategy (missed cancers), approaches were developed to increase the total number of biopsies and to change the location of the biopsies. While there is disagreement about the optimal strategy, most would agree that initial prostate biopsy strategies should include at least 10-14 cores. Additional concerns have been raised about drawing conclusions about the stage (grade) of prostate cancer based on limited biopsy material. Use of multiple biopsies has also been discussed as an approach to identify tumors that may be eligible for sub-total cryoablation therapy.

At present, many practitioners use a 12 to 14 core “extended” biopsy strategy for patients undergoing initial biopsy. This extended biopsy is done in office setting.

Another approach to increase the number of biopsy tissue cores is use of the “saturation” biopsy. In general, saturation biopsy is considered as a minimum of 20 cores taken from the prostate. While saturation biopsy can also be performed in an office-based setting, some perform this approach with general anesthesia. 

Indications for Cryoablation of Prostate Cancer are addressed in another policy.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member’s specific benefit plan language.

11/19/2009: Approved by MPAC

12/13/2012: Policy reviewed; no changes.

This is not intended to be a comprehensive list of codes. Some covered procedure codes have multiple descriptions.

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document.

Covered Codes

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