Anthem Blue Cross Connecticut CG-MED-45 Transrectal Ultrasonography Form

This document addresses the use of transrectal ultrasonography in the diagnosis, staging, and management of conditions involving the prostate, rectum, uterus, vaginal canal and surrounding tissues.

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

• CG-SURG-98 Prostate Biopsy using MRI Fusion Techniques
• SURG.00107 Prostate Saturation Biopsy

Clinical Indications

Medically Necessary:

Transrectal ultrasonography (TRUS) is considered medically necessary for any of the following indications:

1. To guide prostate biopsy when prostate cancer is suspected based on abnormal digital rectal examination (DRE) or prostate-specific antigen (PSA) level greater than 3.0 ng/ml or medical history; or
2. To guide application of cryotherapy or brachytherapy for treatment of prostate cancer; or
3. To evaluate and stage prostate cancer or rectal cancer; or
4. To evaluate and guide treatment for any of the following:
   1. Anal, rectal, or peri-rectal abscess, tumors, fistula, or anal sphincter dysfunction; or
   2. Infertility associated with ejaculatory duct obstruction; or
   3. Hematospermia (hemospermia); or
   4. Benign prostatic hyperplasia (BPH), prostate abscess, prostatic calculi, or prostatitis; or
   5. Pelvic masses, pelvic inflammatory conditions, or rectovaginal endometriosis; or
   6. Suspected congenital anomalies of the prostate, rectum, or surrounding tissue (for example: uterus, or vaginal canal).

Not Medically Necessary:

Transrectal ultrasonography (TRUS) is considered not medically necessary when criteria are not met and for all other indications, including but not limited to use as a primary screening test for prostate cancer.