Wiki Medicare policies on medical necessity

[jennlester71]

Some things are very easily searchable on CMS.gov regarding CPT codes, fee schedules, etc.

I'm having trouble finding what the medical necessity policy is on a saturation biopsy, code 55706. I know it is a covered code, but how do I find out specifics about what medicare considers medical necessity for performing that vs a regular biopsy if there is a regular biopsy 55700 pathology report that already shows positive for prostate cancer. The saturation biopsy comes because of a rise in PSA, so I don't know if the saturation is to see if it's spread further. Any advice on where to find this information would be greatly appreciated.

 

[SharonCollachi]

From the American Urological Association:

55706 : Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidance

CPT code 55706 is the code to use for the performance of a “saturation” biopsy. A true saturation biopsy is a very involved procedure with specific indications and defined steps that must be performed, as follows:

• Patient has a prior suspicious biopsy, or a prior negative biopsy with rising PSA
• The procedure is performed an operating room under general or spinal anesthesia
• A template grid to map the (entire) prostate gland. This grid enables the physician to remove cores at 5-mm intervals using a stereotactic approach.
• Cores are taken at 5mm intervals, and labeling each specimens to correspond to location of each core chosen. In deeper planes, both a proximal and distal biopsy may be obtained.
• Each biopsy sample is marked for its coordinates, and all are mapped in 3D to determine the extent and exact position of malignant cells.
• Typically, 35-60 biopsies are taken, based upon the size of the gland

It is important to understand that this code was specifically created for the unique situation where a saturation biopsy is indicated. This procedure is not meant to sample but rather to enable the systematic collection of samples from the entire prostate gland. CPT 55706 should not be used for an initial biopsy, nor merely because the procedure is being performed by the perineal approach, even if under general anesthesia in an operating room and even if using a template, stepper or grid. CPT Code 55706 cannot be performed in the office so there are no practice expense inputs except for supplies, clinical staff and equipment used in the follow-up office visits included in the global period. This is a 10-day global procedure with 3 hours and 15 minutes of total time included with a work RVU 6.28.

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Sorry, that's all I could find. I would try to find out when Medicare started covering it, because as recently as 2015, there were numerous commercial coverage articles that deemed it investigational. That might help find more info, if you can narrow down a timeframe.