Anthem Blue Cross Connecticut CG-SURG-98 Prostate Biopsy using MRI Fusion Techniques Form

This document addresses prostate biopsies using a fusion technique in which multiparametric magnetic resonance imaging (mpMRI) is fused with real-time high definition prostate ultrasound images through the use of specialized equipment and software. This enables the ability to target and biopsy areas suspicious for prostate cancer.

Note: Please see the following related documents for additional information:

• CG-MED-45 Transrectal Ultrasonography
• SURG.00107 Prostate Saturation Biopsy

Clinical Indications

Medically Necessary:

The use of multiparametric magnetic resonance imaging fusion with rectal ultrasound for targeted biopsy of the prostate is considered medically necessary for individuals with:

• A persistently elevated or rising prostate specific antigen; and
• An mpMRI with at least one lesion reported on a Likert scale equal to or greater than 3, or scored equal to or greater than 3 according to the Prostate Imaging Reporting and Data System (PI-RADS) scoring system.

Not Medically Necessary:

The use of multiparametric magnetic resonance imaging fusion with rectal ultrasound for targeted biopsy of the prostate is considered not medically necessary when the above criteria are not met and for all other indications.