Download Ultrasound Procedures of the Prostate Gland

MEDICAL POLICY
POLICY TITLE
ULTRASOUND PROCEDURES OF THE PROSTATE GLAND
POLICY NUMBER
MP-5.020
Original Issue Date (Created):
July 9, 2002
Most Recent Review Date
(Revised):
September 9, 2008
Effective Date:
July 31, 2009- RETIRED
I.
DESCRIPTION/BACKGROUND
Ultrasound uses high frequency sound waves to produce images of structures inside the
body. Transrectal ultrasound (TRUS) and prostatic ultrasound are frequently used in the
diagnosis and treatment of disorders of the prostate.
TRUS is an imaging procedure used to diagnose specific conditions involving the rectum,
prostate, genitals, and surrounding tissues. The instruments used in the procedure consist
of a transducer (probe), which is inserted into the rectum, a radial or linear scanner, and an
imaging screen. Sound waves travel through the body and bounce off the internal organs.
The echoes from these waves are translated into an image displayed on an imaging screen.
TRUS is also used to guide transrectal needle biopsy, which can be performed without
anesthesia. TRUS guided biopsies assist the clinician in taking tissue samples necessary
for diagnosis.
Prostatic ultrasound is also used for prostate volume study for brachytherapy treatment
planning for prostate cancer. TRUS of the prostate, including the seminal vesicles of the
testicles, is also used to evaluate male infertility.
II.
DEFINITIONS
AZOOSPERMIA refers to the absence of spermatozoa in the semen.
BRACHYTHERAPY refers to in radiation therapy, the use of implants of radiaoactive
materials such as radium, cesium, iridium, or gold at the treatment site.
OLIGOSPERMIA is a temporary or permanent deficiency of spermatazoa in seminal fluid.
PROSTATE SPECIFIC ANTIGEN (PSA) is a marker for cancer of the prostate, found in the
blood. It is secreted by both benign and malignant prostate tumors, but cancerous prostate
cells secrete it at much higher levels.
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MEDICAL POLICY
POLICY TITLE
ULTRASOUND PROCEDURES OF THE PROSTATE GLAND
POLICY NUMBER
MP-5.020
III.
POLICY
Prostatic ultrasound may be considered medically necessary for the following indications:

Guidance for needle biopsy of the prostate for patients with palpable prostatic
nodules;

Prostate volume study for brachytherapy treatment planning;

Guidance for placement of approved brachytherapy seeds;

Evaluation and diagnosis of patients with abnormal digital rectal exams;

Evaluation and diagnosis of patients with elevated serum prostate specific antigen
(PSA) levels.
Transrectal ultrasound of the prostate, including the seminal vesicles of the testicles, may
be considered medically necessary for infertility evaluation in male patients when any of
the following conditions are present:




Unexplained retrograde ejaculation or loss of ejaculation;
Palpable seminal vesicle abnormality on digital rectal exam;
Low semen volume azoospermia with the absence of severe testicular atrophy;
Low semen volume, severe oligospermia (concentration less than five million).
Transrectal ultrasound to guide biopsy of the prostate may be considered medically
necessary for patients with palpable prostatic nodules.
Cross-references
MP-2.043 Permanent Low Dose Brachytherapy for Prostate Cancer
MP-2.047 Temporary High Dose Brachytherapy for Prostate Cancer
IV.
EXCLUSIONS
The use of prostatic ultrasound for male infertility evaluation when significant sperm are
present on ejaculation is considered not medically necessary as there is no conclusive
evidence that it clearly improves long term outcomes compared with other techniques.
Transrectal ultrasound (without biopsy) is considered investigational for the following
applications, as there is insufficient evidence to support a conclusion concerning the health
outcomes or benefits associated with this procedure:
 Diagnosis of prostate cancer;
 Staging of prostate cancer;
 Screening for prostate cancer;
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[Note: Final page is signature page and is kept on file, but not issued with Policy.]
MEDICAL POLICY
POLICY TITLE
ULTRASOUND PROCEDURES OF THE PROSTATE GLAND
POLICY NUMBER
MP-5.020
 Monitoring the response of prostate cancer to treatment.
V.
BENEFIT VARIATIONS
The existence of this medical policy does not mean that this service is a covered benefit
under the member's contract. Benefit determinations should be based in all cases on the
applicable contract language. Medical policies do not constitute a description of benefits.
A member’s individual or group customer benefits govern which services are covered,
which are excluded, and which are subject to benefit limits and which require
preauthorization. Members and providers should consult the member’s benefit information
or contact Capital for benefit information.
VI.
DISCLAIMER
Capital’s medical policies are developed to assist in administering a member’s benefits, do not constitute
medical advice and are subject to change. Treating providers are solely responsible for medical advice and
treatment of members. Members should discuss any medical policy related to their coverage or condition
with their provider and consult their benefit information to determine if the service is covered. If there is a
discrepancy between this medical policy and a member’s benefit information, the benefit information will
govern. Capital considers the information contained in this medical policy to be proprietary and it may only
be disseminated as permitted by law.
VII. REFERENCES
BCBSA TEC Assessment, 1994; Tab 9.
Okihara K, Kamoi K, Lane RB, Evans RB, Troncoso P, Babaian RJ. Role of systematic
ultrasound-guided staging biopsies in predicting extraprostatic extension and seminal
vesicle invasion in men with prostate cancer. J Clin Ultrasound 2002; 30(3): 123-31.
Park SJ, Miyake H, Hara I, Eto H. Predictors of prostate cancer on repeat transrectal
ultrasound-guided systematic prostate biopsy. Int J Urol 2003; 10(2): 68-71.
Scherr DS, Eastham J, Ohori M, Scardino PT. Prostate biopsy techniques and indications:
when, where, and how? Semin Urol Oncol 2002; 20(1): 18-31.
Smajlovic F. Role of transrectal ultrasonography in evaluating azoospermia causes. Med
Arh 2007; 61(1): 37-9.
Taber's Cyclopedic Medical Dictionary, 19th edition.
Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage
Insurance Company® and Keystone Health Plan® Central. Independent licensees of the Blue Cross and Blue Shield
Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations
for all companies.
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[Note: Final page is signature page and is kept on file, but not issued with Policy.]
MEDICAL POLICY
POLICY TITLE
ULTRASOUND PROCEDURES OF THE PROSTATE GLAND
POLICY NUMBER
MP-5.020
VIII. PRODUCT VARIATIONS
[N] = No product variation, policy applies as stated
[Y] = Standard product coverage varies from application of this policy, see below
[N] CHIP POS
[N] Indemnity
[N] PPO
[N] Special Care
[N] HMO
[N] POS
[N] CHIP HMO
[N] FEP HMO
[N] SeniorBlue
[N] FEP PPO
[N] SeniorBlue PPO
IX.
POLICY HISTORY
MP 5.020
CAC 1/27/04
CAC 5/31/05
CAC 6/28/05
CAC 7/25/06
CAC 7/31/07
CAC 7/29/08
Policy approved for retirement effective 7/31/2009.
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[Note: Final page is signature page and is kept on file, but not issued with Policy.]