Highmark Medicare Services

12102, 12202, 12302, 12501, 12301, 12201

MAC Part A & B

L27534

Thermotherapies (Minimally Invasive Surgical Techniques [MISTs]) for Benign Prostatic Hyperplasia (BPH)

L27534

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

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

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 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Pennsylvania, Maryland, District of Columbia, Delaware

Central Office

For services performed on or after 07/11/2008

N/A

For services performed on or after 08/01/2008

08/31/2008

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

Thermotherapies (Minimally Invasive Surgical Techniques [MISTs]) of the prostate are nonsurgical approaches for the treatment of benign prostatic hypertrophy (BPH). Various energy sources are used to destroy prostatic tissue.

Thermotherapies or MISTs are covered by Medicare only for the treatment of outlet obstruction caused by benign prostatic hyperplasia.

Indications

Thermotherapies or MISTs are covered for the treatment of outlet obstruction caused by benign prostatic hyperplasia when ALL of the following patient criteria exist:

1. Diagnosis of symptomatic BPH with duration of symptoms greater than 3 months;
2. A recent PSA (within 12 months of the procedure) that resulted in a value of 2.5 ng/ml or less for patients up to the age of 60, 4.0 ng/ml or less for patients over 60. If the PSA is greater than these specified values, an ultrasound guided biopsy of the prostate should be performed prior to the procedure;
3. A failed trial of satisfactory voiding with medication (alpha-blocker and/or 5-alpha-reductase inhibitor) or intolerance to medication (alpha-blocker and/or 5-alpha-reductase inhibitor).
4. Peak urine flow rate (Qmax) less than 15 cc/sec

Thermotherapies or MISTs are contraindicated for the treatment of BPH when the following conditions exist:

• Active urinary tract infection
• Prostate malignancy
• Prostate gland with an obstructive median lobe
• Hyperreflexive neurogenic bladder
• Previous prostate surgery
• Active cystolithiasis
• Gross hematuria
• Urethral stricture
• Bladder neck contracture
• Acute prostatitis
• Prior radiation therapy to the pelvic area
• Presence of pacemaker or hip implant if microwave therapies are used

In rare instances the following patients may benefit from a MIST procedure:

• A patient who has prostate cancer, is not a candidate for surgical resection of the prostate but will be treated by radiation therapy AND has symptoms that are so severe that immediate relief is required.
  
• A patient who has a past history of prostate cancer but is clinically in remission as evidenced by a PSA < 1.0 ng/ml.

Limitations

The medical literature does not clearly establish the clinical efficacy of these procedures for conditions other than hyperplasia of the prostate. Therefore, any diagnosis other than hyperplasia of the prostate is not covered.

Any MIST procedure performed on a patient who does not meet the patient selection criteria outlined in the "Indications and Limitations of Coverage and/or Medical Necessity" section of this policy.

When a MIST procedure is performed and the patient is exhibiting any of the contraindications outlined in the "Indications and Limitations of Coverage and/or Medical Necessity" section of this policy, despite the diagnosis of BPH, this procedure will be considered non-covered.

Surgical Services

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

N/A

All those not listed under the “ICD-9 Codes that Support Medical Necessity” section of this policy.

Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.

1. All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
   
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)).  The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
   
3. The submitted medical record should support the use of the selected ICD-9-CM code(s).  The submitted CPT/HCPCS code should describe the service performed.

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

Other Contractor’s Policies

Highmark Medicare Services Contractor Medical Directors

This policy does not reflect the sole opinion of the contractor or Contractor Medical Directors. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).

CAC/IAC Distribution: 04/01/2008

05/15/2008

05/23/2008

L27534

07/31/2008

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