Does 55880 require prior authorization?

No, 55880 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 55880?

Medicare facility rate: $879.45. Non-facility rate: $879.45. Work RVU: 17.29.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

17.29

Facility

$879.45

Non-Facility

$879.45

Implied / inferable documentation (not explicitly listed in policy but required to establish the covered indication): documentation of prior radiotherapy and evidence of local (intra-prostatic) recurrence (e.g., biopsy-proven recurrent prostate cancer), documentation demonstrating absence of metastatic disease (e.g., bone scan, pelvic MRI, or other staging studies), and medical records supporting that the indication is 'radio-recurrent prostate cancer' for which HIFU is being considered.
CPT 55880 is 'covered when selection criteria are met' — the policy does not list the selection criteria in this excerpt, so documentation showing that the patient meets those selection criteria would be required (e.g., records of prior treatments, PSA trajectory/biochemical recurrence definitions, biopsy and imaging results).
Breast fibroadenoma: 'All patients with FA underwent core needle biopsy with histological confirmation.'

Aetna considers high intensity focused ultrasound (HIFU) medically necessary for radio-recurrent prostate cancer in the absence of metastatic disease.
CPT codes covered when selection criteria are met: 55880 Ablation of malignant prostate tissue, transrectal, with high intensity-focused ultrasound (HIFU), including ultrasound guidance
ICD-10 codes covered if selection criteria are met: C61 Malignant neoplasm of prostate [radio-recurrent prostate cancer]
Benign thyroid nodules
Acute fractures in adults (use of HIFU/LIUS/ECSW as part of fracture treatment) — studied but evidence insufficient
Breast cancer (non-invasive HIFU ablation to induce coagulative necrosis; complete ablation inconsistent)

AETNA-CPB-0766 — High Intensity Focused Ultrasound

HUMANA-HYPERTHERMIA-FOR-TREATMENT-OF-CANCER-MA — Hyperthermia for Treatment of Cancer - Medicare Advantage

ANTHEM-CG-MED-81 — CG-MED-81 Ultrasound Ablation for Oncologic Indications

BCBSIL-SUR717.004 — Focal Treatments for Prostate Cancer

BCBSMT-SUR717.004 — Focal Treatments for Prostate Cancer

Ask Verity about documentation requirements, denial risks, or coverage in your state.