CurrentBlue Cross Blue Shield - NebraskaPolicy M.43

MA Prostate Rectal Spacers (Preauthorization Required)

Customize your policy alerts

Sign up for Blue Cross Blue Shield - Nebraska Policy M.43 alerts

Get alerted when Policy M.43 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy governing preauthorization and medical necessity criteria for implantation of biodegradable perirectal (prostate-rectal) spacers to reduce rectal radiation dose in patients receiving radiation therapy for localized or locally advanced prostate cancer.

Policy Summary

PayerBlue Cross Blue Shield - Nebraska

PolicyMA Prostate Rectal Spacers (Preauthorization Required)

Policy CodePolicy M.43

Change TypeNo material change

Effective DateJan 1, 2026

Last ReviewApr 1, 2026

Next Review DateNov 4, 202612d

Key ActionObtain preauthorization and document diagnosis, prostate volume, prior prostate surgery/radiation history, planned hypofractionated radiation modality, coagulation labs, and imaging excluding rectal invasion.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

I–IIIEligible cancer stages

<80 ccProstate volume limit

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentBlue Cross Blue Shield - NebraskaPolicy M.43

MA Prostate Rectal Spacers (Preauthorization Required)

Customize your policy alerts

Sign up for Blue Cross Blue Shield - Nebraska Policy M.43 alerts

Get alerted when Policy M.43 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerBlue Cross Blue Shield - Nebraska

PolicyMA Prostate Rectal Spacers (Preauthorization Required)

Policy CodePolicy M.43

Change TypeNo material change

Effective DateJan 1, 2026

Last ReviewApr 1, 2026

Next Review DateNov 4, 202612d

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

I–IIIEligible cancer stages

<80 ccProstate volume limit

Plt ≥100; INR ≤1.5; aPTT ≤50s

~3 moSpacer duration

Coverage Criteria for Perirectal (Prostate-Rectal) Spacers

Covered when ALL criteria are met

Prostate rectal spacers may be considered reasonable and necessary when ALL the following are met:

Primary coverage criteria: A. Diagnosis of localized or locally advanced prostate cancer (Stage I - III) with no lymph node involvement

Primary coverage criteria: B. Planned hypofractionated radiation therapy (hypofractionated-IMRT, hypofractionated high dose rate brachytherapy, hypofractionated EBRT, or stereotactic body radiotherapy)

Primary coverage criteria: C. Prostate volume is less than 80 cc< 80 cc

Primary coverage criteria: D. No prior surgery or radiation for prostate cancer treatment

Primary coverage criteria: E. No active bleeding and coagulation laboratory thresholds met: platelet count ≥ 100 × 10(9)/L, INR ≤ 1.5, and aPTT ≤ 50 seconds

Primary coverage criteria: F. No tumor invasion into the rectum and no posterior extraprostatic extension

Patients with evidence of direct tumor extension into the rectum or with visible posterior extraprostatic extension (eg, clinical or imaging findings consistent with T3 disease involving the posterior aspect of the prostate) are not candidates for perirectal spacer implantation. The policy requires no tumor invasion into the rectum and no posterior extraprostatic extension as a condition of coverage; spacer placement in the presence of these findings is contraindicated and should not be performed.

Prostate rectal spacers are not medically necessary when the policy’s required criteria A–F are not all met. Approval for perirectal spacer implantation is contingent on meeting every listed criterion (diagnosis and stage, planned hypofractionated radiation, prostate volume <80 cc, no prior prostate surgery or radiation, coagulation/lab thresholds, and absence of rectal invasion or posterior extraprostatic extension).

Coding and Clinical Thresholds

Covered CPT CodesCPTCovered

55874

TRANSPERINEAL PLMT BIODEGRADABLE MATRL 1/MLT NJX - Transperineal placement of biodegradable material, peri-prostatic, single or multiple injection(s), including image guidance, when performed

inv-05: Prostate volume threshold

Prostate volume thresholdProstate volume is less than 80 cc

Source contextCriterion C in coverage criteria: 'The prostate volume is less than 80 cc'

RelevanceRequired for coverage approval of perirectal spacer implantation

inv-06: Platelet count threshold

Platelet count thresholdPlatelet count ≥ 100 × 10^9/L

Source contextCriterion E lists: 'no active bleeding or platelet count <100×10(9)/l' (coverage requires not having platelet count <100×10^9/L)

Prior Authorization, Documentation, and Denial Conditions

Prior Authorization

Preauthorization required for CPT 55874

Preauthorization is required for CPT 55874 (transperineal placement of biodegradable material, peri‑prostatic). Approval is contingent on documentation that the patient meets all medical necessity criteria listed in the policy (items A–F).

CPT 55874: Transperineal placement of biodegradable material, peri‑prostatic (single or multiple injections, including image guidance when performed).
Approval requires that all coverage criteria A–F (diagnosis, planned hypofractionated radiation, prostate volume <80 cc, no prior prostate surgery/radiation, coagulation thresholds, and no rectal invasion/posterior extraprostatic extension) are met.

Note

Procedural note — preserve source language

Preserve the original policy language and procedural details when submitting requests and documentation to the payer; no additional step‑therapy requirements are specified in this policy.

Follow policy criteria A–F exactly as written when planning the procedure.

Background on Perirectal Spacers

Perirectal spacers (for example, polyethylene glycol hydrogel products such as SpaceOAR or hyaluronic acid spacers) are implanted between the prostate and rectum to increase separation and reduce rectal radiation dose and toxicity. These biodegradable materials are placed peri-prostatically to protect rectal tissues during external beam or brachytherapy radiation; the policy notes the clinical intent is to reduce rectal irradiation and related toxicity during hypofractionated radiation courses.

Cancer Stage Definitions

inv-14: Stage I definition

Stage I definitionCancer is usually slow growing, not palpable, involves one-half of one side of the prostate or less; PSA levels are low; cancer cells look like healthy cells.

Clinical featuresTumor cannot be felt and involves ≤ half of one prostate lobe; low PSA; well-differentiated cells.

Coverage relevanceStage I is included among eligible stages (Stage I - III) when all criteria are met.

inv-15: Stage II (IIA, IIB, IIC) definition

Stage II overallTumor confined to the prostate; PSA levels low to medium; stage includes subcategories IIA, IIB, IIC describing extent and differentiation.

Stage IIATumor cannot be felt and involves half of one side or less; PSA medium; cells well differentiated; includes larger tumors still well differentiated.

Policy Summary

PayerBlue Cross Blue Shield - Nebraska

PolicyMA Prostate Rectal Spacers (Preauthorization Required)

Policy CodePolicy M.43

Change TypeNo material change

Effective DateJan 1, 2026

Last ReviewApr 1, 2026

Next Review DateNov 4, 202612d

SourceLink

On This Page

Required coagulation lab for preauthorization documentation and medical necessity

inv-07: INR threshold

INR thresholdINR ≤ 1.5

Source contextCriterion E: 'international normalized ratio >1.5' (coverage requires INR not to be >1.5)

RelevanceRequired coagulation lab for preauthorization documentation and medical necessity

inv-08: aPTT threshold

aPTT thresholdaPTT ≤ 50 seconds

Source contextCriterion E: 'activated partial thromboplastin time >50 seconds' (coverage requires aPTT not to be >50 seconds)

RelevanceRequired coagulation lab for preauthorization documentation and medical necessity

There is no step‑therapy protocol or alternative treatment sequencing described in the policy.

Documentation Required

Preauthorization documentation requirements

For preauthorization, include clinical documentation showing diagnosis, prostate volume, prior prostate surgery/radiation history, planned hypofractionated radiation modality, coagulation labs, and imaging/evidence excluding rectal tumor invasion or posterior extraprostatic extension.

Diagnosis of localized or locally advanced prostate cancer (Stage I–III) with no lymph node involvement.
Planned hypofractionated radiation therapy modality (eg, hypofractionated‑IMRT, hypofractionated HDR brachytherapy, hypofractionated EBRT, or stereotactic body radiotherapy).
Prostate volume (< 80 cc).
History of no prior prostate surgery or radiation.
Coagulation labs: platelet count (≥100×10^9/L implied by policy threshold), INR (≤1.5), aPTT (≤50 seconds).
Imaging or documentation confirming no tumor invasion into the rectum and no posterior extraprostatic extension.

Denial Risk

Denial risk if coverage criteria A–F not met

Requests will be considered not medically necessary and may be denied when ALL policy criteria A–F are not met.

Criteria A–F include: diagnosis (Stage I–III, no nodal involvement), planned hypofractionated radiation, prostate volume <80 cc, no prior prostate surgery/radiation, acceptable coagulation parameters, and no rectal invasion/posterior extraprostatic extension.

Stage IIB/IICIIB: Tumor inside prostate, may be felt on DRE, PSA medium, moderately differentiated. IIC: Tumor inside prostate, may be felt on DRE, PSA medium, cells moderately or poorly differentiated.

inv-16: Stage III (IIIA, IIIB, IIIC) definition

Stage III definitionLocally advanced disease with high PSA, tumor growth, or high-grade cancer indicating likelihood to grow and spread.

Stage IIIACancer has spread beyond outer layer of prostate into nearby tissues; may involve seminal vesicles; PSA high.

Stage IIIB/IIICIIIB: Tumor grown outside prostate and may have invaded nearby structures such as bladder or rectum. IIIC: Tumor cells poorly differentiated (look very different from healthy cells).

inv-17: Stage IV definition

Stage IV definitionCancer has spread beyond the prostate to regional lymph nodes or distant sites; includes IVA (regional lymph nodes) and IVB (distant lymph nodes, other parts of the body, or bones).

SubcategoriesIVA: spread to regional lymph nodes. IVB: spread to distant lymph nodes, other body parts, or bones.

Coverage relevanceStage IV is not listed among eligible stages; policy eligibility is limited to Stage I–III when all criteria are met.