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HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Documentation of prior non-diagnostic TRUS-guided prostate biopsy, including date of procedure (must be within prior 12 months).
- PSA values showing a persistently rising trend when claiming elevated PSA as the indication.
- Prior prostate biopsy pathology report documenting atypia or high-grade PIN when claimed as the indication.
- Clinical documentation of a palpable lesion on DRE when claiming DRE findings as the indication.
Key Coverage Criteria
- Saturation biopsy for diagnosis of prostate cancer when initial evaluation indicates need for extensive sampling
- Saturation biopsy for staging of known prostate cancer to assess extent and multifocality
- Saturation biopsy, including comprehensive 3D mapping, to guide management decisions (e.g., treatment planning or active surveillance)
- Men with a prior non-diagnostic transrectal ultrasound-guided (TRUS) prostate biopsy performed within the prior 12 months and a persistently rising prostate-specific antigen (PSA).
- Men with a prior non-diagnostic TRUS prostate biopsy performed within the prior 12 months and histologic evidence of atypia on the prior biopsy.
- Men with a prior non-diagnostic TRUS prostate biopsy performed within the prior 12 months and histologic findings of high-grade prostatic intraepithelial neoplasia (PIN) on the prior biopsy.
5 Active Policies
BCBSIL-SUR717.015 — Saturation Biopsy for Diagnosis, Staging and Management of Prostate Cancer, Including Comprehensive 3D Mapping with Biopsy
BCBSMT-SUR717.015 — Saturation Biopsy for Diagnosis, Staging and Management of Prostate Cancer, Including Comprehensive 3D Mapping with Biopsy
BCBSNM-SUR717.015 — Saturation Biopsy for Diagnosis, Staging and Management of Prostate Cancer, Including Comprehensive 3D Mapping with Biopsy
BCBSOK-SUR717.015 — Saturation Biopsy for Diagnosis, Staging and Management of Prostate Cancer, Including Comprehensive 3D Mapping with Biopsy
Related Codes
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