Medicare Advantage Medical Policy Bulletin
Section: CMS National Guidelines
Number: N-133
Topic: Cryosurgery of the Prostate - NCD 230.9
Effective Date: January 1, 2008
Issued Date: April 13, 2009

General Policy

Cryosurgery of the prostate gland is also known as cryosurgical ablation of the prostate (CSAP). This is a procedure which destroys prostate tissue by applying extremely cold temperatures in order to reduce the size of the prostate gland.

Indications and Limitations of Coverage

Cryosurgery of the prostate gland is considered eligible as primary treatment for patients with clinically localized prostate cancer, Stages T1-T3 (185). Services performed for other diagnoses and/or conditions are denied as not medically necessary. Effective January 26, 2009, a provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

Salvage cryosurgery of prostate after radiation failure
Salvage cryosurgery of the prostate for recurrent cancer is medically necessary and appropriate only for those patients with recurrent localized disease, have failed a trial of radiation therapy as their primary treatment; and meet one of the following conditions: 

Reasons for Noncoverage

Cryosurgery as salvage therapy is not covered after failure of other therapies as the primary treatment.

Cryosurgery as salvage is only covered after the failure of a trial of radiation therapy, under the conditions noted above.

NOTE:
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 circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

55873     

Coding Guidelines

Procedure code 55873 includes payment for both the cryosurgical ablation and the ultrasonic guidance. In situations where one provider has provided the cryosurgical ablation and another has provided the ultrasonic guidance, for the same patient, for the same date of service, the provider of the cryosurgical ablation must submit the claim. The provider of the ultrasonic guidance must then seek compensation from the provider of the cryosurgical ablation.

References

Title XVIII of the Social Security Act, Section 1862 (a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862 (a)(1)(A) states that no payment shall be made for items or services which are not medically reasonable and necessary.

Title XVIII of the Social Security Act, Section 1833 (e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS Online Manual Pub. 100-3, NCD 230.9

CMS Online Manual Pub. 100-4, Chapter 18, Sec. 51.1-51.3

CMS Transmittal 1689, CR 1457

CMS Transmittal 1710, CR 1632

CMS Transmittal 140, CR 1632

CMS Transmittal 260, CR 3168

www.cms.gov
www.medicare.gov

Attachments

Procedure Code Attachments

Diagnosis Codes

185   

Glossary




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 circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Medicare Advantage plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Medicare Advantage retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Medicare Advantage. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.