Prostatectomy Form

. The prostate is a walnut-sized gland located in front of the rectum and just below the bladder that forms part of the male reproductive system. The prostate gland surrounds the urethra, the canal through which urine passes out of the body. Prostate cancer is the most commonly diagnosed cancer, excluding skin cancer, and is the second leading cause of cancer death in North American males. Localized prostate cancer (confined to the prostate gland) may be curable and even if widespread, frequently responds to treatment. However, survival and prognosis are greatly influenced by a number of factors such as age of the individual, disease stage, grade of the tumor and the presence of comorbid medical conditions. Prostatectomy involves the removal of the prostate gland, with or without nerve sparing and surrounding tissues usually includes the seminal vesicles and some

Prostatectomy Effective Date: 02/02/2023 Revision Date: 02/02/2023 Review Date: 02/02/2023 Policy Number: HUM-0575-005 Page: 2 of 9 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. nearby lymph nodes. Examples of prostatectomy techniques include, but may not be limited to, the following: Laparoscopic prostatectomy is a surgical procedure where the surgeon makes several small incisions in the lower abdomen and inserts special tools to remove the prostate. Open prostatectomy is a surgical procedure where the surgeon removes the prostate through an incision in the lower abdomen or, less commonly, through a perineal incision. For information regarding prostatectomy for benign prostatic hyperplasia (BPH), please refer to Benign Prostatic Hyperplasia Treatments Medical Coverage Policy. Coverage Determination Humana members may be eligible under the Plan for prostatectomy when the following criteria are met: • Localized (T1 [organ confined] through T3 [locally advanced]) prostate cancer without fixation to adjacent structures (eg, bladder, pelvic wall or rectum); OR • Salvage therapy for local recurrence, following failure of external beam radiation therapy (EBRT), brachytherapy or cryotherapy;
AND all of the following: • Life expectancy of 10 years or greater; AND • No distant metastases; AND
• No evidence of regional lymph node involvement Coverage Limitations Humana members may NOT be eligible under the Plan for prostatectomy for any indications other than those listed above. All other indications are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition. See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only.

Prostatectomy Effective Date: 02/02/2023 Revision Date: 02/02/2023 Review Date: 02/02/2023 Policy Number: HUM-0575-005 Page: 3 of 9 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. Background Additional information about prostate cancer may be found from the following websites: • American Cancer Society • American Urological Association • National Cancer Institute • National Comprehensive Cancer Network • National Library of Medicine Medical Alternatives Alternatives to prostatectomy include, but may not be limited to, the following: • Active surveillance • Brachytherapy (please refer to Brachytherapy Medical Coverage Policy). • Cryotherapy (please refer to Cryoablation Medical Coverage Policy). • Hormone therapy • Prescription drug therapy • Radiation therapy (please refer to Intensity Modulated Radiation Therapy or Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy Medical Coverage Policies). • Watchful waiting Physician consultation is advised to make an informed decision based on an individual’s health needs.
Humana may offer a disease management program for this condition. The member may call the number on his/her identification card to ask about our programs to help manage his/her care. See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only.

Prostatectomy Effective Date: 02/02/2023 Revision Date: 02/02/2023 Review Date: 02/02/2023 Policy Number: HUM-0575-005 Page: 4 of 9 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. Provider Claims Codes Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure. CPT® Code(s) 55801 55810 55812 55815 55821 55831 55840 55842 55845 55866 Description Comments Prostatectomy, perineal, subtotal (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy) Prostatectomy, perineal radical; Prostatectomy, perineal radical; with lymph node biopsy(s) (limited pelvic lymphadenectomy) Prostatectomy, perineal radical; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric and obturator nodes Prostatectomy (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy); suprapubic, subtotal, 1 or 2 stages Prostatectomy (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy); retropubic, subtotal Prostatectomy, retropubic radical, with or without nerve sparing; Prostatectomy, retropubic radical, with or without nerve sparing; with lymph node biopsy(s) (limited pelvic lymphadenectomy) Prostatectomy, retropubic radical, with or without nerve sparing; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only.

Prostatectomy Effective Date: 02/02/2023 Revision Date: 02/02/2023 Review Date: 02/02/2023 Policy Number: HUM-0575-005 Page: 5 of 9 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. Laparoscopy, surgical prostatectomy, simple subtotal (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy), includes robotic assistance, when performed New Code Effective 01/01/2023 Description Comments 55867 CPT® Category III Code(s) No code(s) identified HCPCS Code(s) No code(s) identified References

5. Description Comments Agency for Healthcare Research and Quality (AHRQ). Comparative Effectiveness Review. Therapies for clinically localized prostate cancer. https://www.ahrq.gov. Published September 2020. Accessed November 30,

   2022. American Cancer Society (ACS). Surgery for prostate cancer. https://www.cancer.org. Published August 1, 2019. Accessed December 1,
   2023. American Urological Association (AUA). AUA/ASTRO Guideline. Clinically localized prostate cancer. https://www.auanet.org. Published 2022. Accessed December 1, 2022. ECRI Institute. Clinical Evidence Assessment. Outpatient robot-assisted radical prostatectomy for treating localized prostate cancer. https://www.ecri.org. Published June 16, 2022. Accessed November 30, 2022. ECRI Institute. Emerging Technology Evidence Report. Robotic-assisted laparoscopic radical prostatectomy for localized prostate cancer. https://www.ecri.org. Published August 2, 2005. Updated May 17, 2010. Accessed November 30, 2022. See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only.

   Prostatectomy Effective Date: 02/02/2023 Revision Date: 02/02/2023 Review Date: 02/02/2023 Policy Number: HUM-0575-005 Page: 6 of 9 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

8. ECRI Institute. Technology Forecast. Prostate cancer. https://www.ecri.org. Published December 2, 2003. Updated July 7, 2014. Accessed November 30, 2022. Hayes, Inc. Medical Technology Directory (ARCHIVED). Laparoscopic radical prostatectomy. https://evidence.hayesinc.com. Published July 5, 2005. Updated June 22, 2009. Accessed November 30, 2022. Hayes, Inc. Medical Technology Directory (ARCHIVED). Robotic-assisted prostatectomy. https://evidence.hayesinc.com. Published April 28, 2008. Updated March 13, 2012. Accessed November 30, 2022.
9. MCG Health. Prostatectomy, radical. 26th edition. https://www.mcg.com. Accessed November 8, 2022.
10. National Cancer Institute (NCI). Prostate cancer treatment (PDQ) – health professional version. https://www.cancer.gov. Updated October 14, 2022. Accessed December 1, 2022.
11. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Prostate cancer. https://www.nccn.org. Published September 16, 2022. Accessed December 1, 2022.
12. UpToDate, Inc. Active surveillance for males with clinically localized prostate cancer. https://www.uptodate.com. Updated October 2022. Accessed November 30, 2022.
13. UpToDate, Inc. Cryotherapy and other ablative techniques for the initial treatment of prostate cancer. https://www.uptodate.com. Updated November 23, 2022. Accessed November 30, 2022.
14. UpToDate, Inc. Initial approach to low- and very low-risk clinically localized prostate cancer. https://www.uptodate.com. Updated October 2022. Accessed November 30, 2022.

15. UpToDate, Inc. Initial management of regionally localized intermediate-, high-, and very high-risk prostate cancer and those with clinical lymph node See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only.

    Prostatectomy Effective Date: 02/02/2023 Revision Date: 02/02/2023 Review Date: 02/02/2023 Policy Number: HUM-0575-005 Page: 7 of 9 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. involvement. https://www.uptodate.com. Updated October 2022. Accessed November 30, 2022.

16. UpToDate, Inc. Localized prostate cancer: risk stratification and choice of initial treatment. https://www.uptodate.com. Updated October 2022. Accessed November 30, 2022.
17. UpToDate, Inc. Prostate cancer in older males. https://www.uptodate.com. Updated October 2022. Accessed November 30, 2022.

18. UpToDate, Inc. Radical prostatectomy for localized prostate cancer. https://www.uptodate.com. Updated October 3, 2022. Accessed November 30, 2022. See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only.

    Prostatectomy Effective Date: 02/02/2023 Revision Date: 02/02/2023 Review Date: 02/02/2023 Policy Number: HUM-0575-005 Page: 8 of 9 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. Appendix A TNM Staging System for Prostate Cancer11 Primary tumor (T) Clinical T (cT) T category TX T0 T1 T1a T1b T1c T2 T2a T2b T2c T3 T3a T3b T4 T criteria Primary tumor cannot be assessed No evidence of primary tumor Clinically inapparent tumor that is not palpable Tumor incidental histologic finding in 5% or less of tissue resected Tumor incidental histologic finding in more than 5% of tissue resected Tumor identified by needle biopsy found in one or both sides, but not palpable Tumor is palpable and confined within prostate Tumor involves one-half of one side or less Tumor involves more than one-half of one side but not both sides Tumor involves both sides Extraprostatic tumor that is not fixed or does not invade adjacent structures Extraprostatic extension (unilateral or bilateral) Tumor invades seminal vesicle(s) Tumor is fixed or invades adjacent structures other than seminal vesicles such as external sphincter, rectum, bladder, levator muscles, and/or pelvic wall. Pathological T (pT) T category T2 T3 T3a T3b T4 T criteria Organ confined Extraprostatic extension Extraprostatic extension (unilateral or bilateral) or microscopic invasion of bladder neck Tumor invades seminal vesicle(s) Tumor is fixed or invades adjacent structures other than seminal vesicles such as external sphincter, rectum, bladder, levator muscles, and/or pelvic wall Note: There is no pathological T1 classification. Note: Positive surgical margin should be indicated by an R1 descriptor, indicating residual microscopic disease. Regional lymph nodes (N) N category N criteria NX N0 N1 Regional lymph nodes cannot be assessed No positive regional nodes Metastases in regional node(s) See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only.

    Prostatectomy Effective Date: 02/02/2023 Revision Date: 02/02/2023 Review Date: 02/02/2023 Policy Number: HUM-0575-005 Page: 9 of 9 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. Distant metastasis (M) M category M criteria M0 M1 M1a M1b M1c Note: When more than one site of metastasis is present, the most advanced category is used. M1c is most advanced. No distant metastasis Distant metastasis Nonregional lymph node(s) Bone(s) Other site(s) with or without bone disease See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only.