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DESCRIPTIONSaturation biopsy, in which more cores are obtained than by standard biopsy protocol, has been proposed in the diagnosis (for initial or repeat biopsy), staging, and management of patients with prostate cancer.
Prostate cancer is a common cancer and is the second leading cause of cancer-related deaths in men in the United States. 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 and allows for more extensive sampling of the lateral peripheral zone; sampling of the lateral horn may increase the cancer detection rate by approximately 25%.
Another approach to increase the number of biopsy tissue cores is use of the “saturation” biopsy. In general, saturation biopsy is considered as more than 20 cores taken from the prostate, with improved sampling of the anterior zones of the gland, which may be undersampled in standard peripheral zone biopsy strategies and may lead to 17% of cancers being missed, according to one study. Saturation biopsy may be performed transrectally or with a transperineal approach; the transperineal approach is generally performed as a stereotactic template-guided procedure with general anesthesia.
Indications for Cryoablation of Prostate Cancer are addressed in another policy.
POLICYSaturation biopsy, taking 20 or more core tissue samples at one time, is considered medically necessary in the diagnosis, staging, and management of prostate cancer.
POLICY EXCEPTIONSFederal Employee Program (FEP): Saturation biopsy, taking 20 or more core tissue samples at one time, is considered investigational in the diagnosis, staging, and management of prostate cancer.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member’s specific benefit plan language.
POLICY HISTORY10/21/2009: Policy Added
11/19/2009: Approved by MPAC
12/13/2012: Policy reviewed; no changes.
03/27/2014: Policy reviewed; no changes to policy statement. Removed ICD-9 procedure code 92.39 from the Code Reference section.
12/31/2014: Code Reference section updated to revise the description of the following HCPCS code: G0416.
08/27/2015: Code Reference section updated to add ICD-10 codes.
02/29/2016: Policy description updated. Policy statement unchanged. Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to remove the following deleted HCPCS codes: G0417, G0418, and G0419.
05/31/2016: Policy number added.
SOURCESBlue Cross Blue Shield Association policy # 7.01.121
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessasry if the procedure is performed according to the "Policy" section of this document.