0601T — Abltj ire 1+tumors open
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
- This article provides billing, coding, and guideline information that complements the Local Coverage Determination DL40205 for Irreversible Electroporation for Cancer; refer to LCD DL40205 for clinical coverage criteria.
- Minimum 5-year follow-up period documented after focal therapy.
- Multiparametric MRI results during follow-up.
- Follow-up biopsy reports.
Key Coverage Criteria
- Whole-gland cryosurgical ablation as initial treatment for clinically localized (organ-confined) prostate cancer.
- Whole-gland cryosurgical ablation as salvage treatment for prostate cancer recurring after radiation therapy.
- Whole-gland cryoablation as a percutaneous procedure to treat localized prostate cancer by freezing and thawing prostate tissue to induce tumor necrosis.
- Whole-gland (total) cryoablation for treatment of clinically localized prostate cancer as an alternative to radical prostatectomy or external-beam radiotherapy.
- Whole-gland cryoablation as salvage therapy for nonmetastatic relapse after initial treatment of clinically localized prostate cancer.
- Subtotal (focal) prostate cryoablation for treatment of localized prostate cancer (focal treatment of the gland).
13 Active Policies
A60221 — Billing and Coding: Irreversible Electroporation for Cancer
L40204 — Irreversible Electroporation for Cancer
BCBSIL-SUR717.004 — Focal Treatments for Prostate Cancer
BCBSMT-SUR717.004 — Focal Treatments for Prostate Cancer
BCBSNM-SUR717.004 — Focal Treatments for Prostate Cancer
Related Codes
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