C9747 — Ablation of prostate, transrectal, high intensity focused ultrasound (hifu), including imaging guidance
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- Coagulopathy or current anticoagulant use which cannot be reversed;or
- Unilateral focused ultrasound thalamotomy is consideredmedically necessaryfor the treatment of adults with essential tremors whenallof the following criteria are met:Moderate to severe tremor of the hand (as defined by a score of 2 or greater on the clinical rating scale for tremor [CRST]);andFailure of 2 or more tremor suppressant medications, as evidenced by persistent moderate to severe tremors, intolerable side effects of drug therapy or contraindications;andAt least 1 of the medications fai [...]
- Moderate to severe tremor of the hand (as defined by a score of 2 or greater on the clinical rating scale for tremor [CRST]);and
- Failure of 2 or more tremor suppressant medications, as evidenced by persistent moderate to severe tremors, intolerable side effects of drug therapy or contraindications;and
- At least 1 of the medications failed was a first line agent (propranolol or primidone).
- Intracranial tumor with significant anatomic distortion.
2 Active Policies
ANTHEM-MED.00057 — MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
ANTHEM-CG-MED-81 — CG-MED-81 Ultrasound Ablation for Oncologic Indications
Related Codes
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