![]() ![]() Repeat biopsy is performed in support of changes in treatment or in support of definitive treatment.Īetna considers transperineal or transrectal magnetic resonance imaging (MRI)-guided prostate biopsy (including the in-bore (direct) approach, and fusion imaging of multi-parametric MRI with TRUS (MRI-TRUS e.g., the UroNav fusion biopsy system) medically necessary for diagnosis, follow-up, and active surveillance of prostate cancer when criteria are met:įor diagnosis when both of the following criteria are met:.Repeat DRE is abnormal and/or rising PSA and/or suspicious MRI and. ![]() Life expectancy of greater than 5 years and.Men with histologic findings of atypia or high-grade prostatic intraepithelial neoplasia (PIN) on prior biopsy.Īetna considers prostate saturation biopsy experimental and investigational for all other indications (e.g., surveillance or watchful waiting of persons with a positive prostate biopsy) because there is insufficient evidence on the clinical utility of this procedure for indications other than the ones listed above in the peer-reviewed medical literature.Īetna considers transrectal ultrasound (TRUS)-guided prostate biopsy medically necessary for diagnosis, follow-up, and active surveillance of prostate cancer when criteria are met:įor diagnosis if serum prostate-specific antigen (PSA) level and/or digital rectal examination (DRE) is abnormal.įor follow-up or active surveillance when all of the following criteria are met:.Men with 2 prior negative prostate biopsies and a prostate specific antigen (PSA) that is persistently rising or.Number: 0698 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background ReferencesĪetna considers a transperineal stereotactic template-guided saturation prostate biopsy medically necessary for the following indications:
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