Wiki Saturation Prostate Biopsy Denials 55706

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toria11

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Hi all,

We have been seeing an increasing number of denials for 55706 from Aetna, BCBS, and Tricare who now seem to be requiring TWO prior negative biopsy results. In the past I always believed it was one. I also recently received a denial from Humana stating our record didn't make it clear that stereotactic guidance was used... Does anyone have any info on where Medicare stands with these indications? Or a general set of rules/indications they follow when billing these?
 
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toria11 said:
Hi all,

We have been seeing an increasing number of denials for 55706 from Aetna, BCBS, and Tricare who now seem to be requiring TWO prior negative biopsy results. In the past I always believed it was one. I also recently received a denial from Humana stating our record didn't make it clear that stereotactic guidance was used... Does anyone have any info on where Medicare stands with these indications? Or a general set of rules/indications they follow when billing these?
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I found a few clinical policies relating to the payers you mentioned.

Aetna -

Medical Necessity​

  1. Aetna considers a transperineal stereotactic template-guided saturation prostate biopsy medically necessary for the following indications:
    • Men with 2 prior negative prostate biopsies and a prostate specific antigen (PSA) that is persistently rising; or
    • Men with histologic findings of atypia or high-grade prostatic intraepithelial neoplasia (PIN) on prior biopsy.
    • Aetna considers prostate saturation biopsy experimental and investigational for all other indications (e.g., surveillance or watchful waiting of persons with a positive prostate biopsy) because there is insufficient evidence on the clinical utility of this procedure for indications other than the ones listed above in the peer-reviewed medical literature.

BCBS - I'm not sure which state's BCBS you were looking for, but I did find a policy for Anthem which states that it is considered investigational and not medically necessary:

 
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I took a quick look on the MCD, but didn't see anything. I'm off to a meeting or else I'd poke around a little more for Medicare info.
 
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