MG Cryosurgical Ablation for Prostate Cancer

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MG Cryosurgical Ablation for Prostate Cancer

Transcript Of MG Cryosurgical Ablation for Prostate Cancer

Cryosurgical Ablation for Prostate Cancer

Last Review Date: October 8, 2021

Number: MG.MM.SU.53c

Medical Guideline Disclaimer
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Definitions Cryosurgery (aka cryotherapy or cryoablation) is a minimally invasive therapy performed with ultrasound guidance that destroys prostate tumor tissue through local freezing. The modality involves either complete or focal ablation (subtotal cryoablation) only targeting diseased tissue while leaving normal tissue intact.
Guideline Cryosurgery is considered medically necessary as salvage therapy for prostate cancer recurrence after treatment with radiation when disease is localized to one lobe of the prostate.

Limitations/Exclusions Salvage therapy is not considered medically necessary when radiation was not utilized as a primary therapy.
Cryosurgery as a primary treatment modality is not considered medically necessary because it is not supported by the National Comprehensive Cancer Network® (NCCN).

Revision History

Oct. 8, 2021
Nov. 11, 2019 Sept. 13, 2019

Updated positive coverage statement to communicate cryotherapy applicability to one lobe, postradiation, and removed test parameter prerequisites of stage T2b or below, and PSA of < 8 ng/mL Removed Gleason Score prerequisite Removed primary treatment as a covered indication

Applicable Procedure Codes


Cryosurgical ablation of the prostate (includes ultrasonic guidance and monitoring)

Applicable ICD-10 Diagnosis Codes


Malignant neoplasm of prostate

Cryoablation for Prostate Cancer Last review: Oct. 8, 2021 Page 2 of 2


Carcinoma in situ of prostate

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