Humana Prostatectomy - Medicare Advantage Form

There are no NCDs and/or LCDs for prostatectomy.

Description

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 Prostatectomy Page: 2 of 7 (confined to the prostate gland) may be curable and even if widespread, frequently responds to treatment. However, survival and prognosis are greatly influenced by several 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. Surrounding tissues usually includes the seminal vesicles and some 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.

Coverage Determination

Humana follows the CMS requirements that only allows coverage and payment for services that are reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member except as specifically allowed by Medicare.

In interpreting or supplementing the criteria above and in order to determine medical necessity consistently, Humana may consider the criteria contained in the following:

Prostatectomy will be considered medically reasonable and necessary when the following requirements 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

The use of the criteria in this Medicare Advantage Medical Coverage Policy provides clinical benefits highly likely to outweigh any clinical harms. Services that do not meet the criteria above are not medically Prostatectomy Page: 3 of 7 necessary and thus do not provide a clinical benefit. Medically unnecessary services carry risks of adverse outcomes and may interfere with the pursuit of other treatments which have demonstrated efficacy.

Coverage Limitations

US Government Publishing Office. Electronic code of federal regulations: part 411 – 42 CFR § 411.15 - Particular services excluded from coverage