CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Cryoablation of Prostate Cancer

Policy governs coverage of whole-gland (and mentions subtotal/focal) cryoablation of clinically localized prostate cancer for Commercial Products; addresses both initial and salvage treatment after radiation. Applies to providers and members under Blue Cross Blue Shield - Rhode Island Commercial Products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyCryoablation of Prostate Cancer

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionVerify member-specific benefits and eligibility with the provider call center and refer to subscriber/employer agreements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Commercial-onlyproduct applicability

55873medically necessary CPT

C61, C79.82, D07.5, Z85.46ICD-10 codes

Not applicablePrior authorization

Coverage Criteria

Medically Necessary Indications

Covered when ANY of the following are met

Initial or salvage treatment: Cryoablation of the prostate is considered medically necessary for clinically localized (organ-confined) prostate cancer when performed as initial treatment or as salvage treatment for disease that recurs following radiation therapy.

Commercial Products only; see related BlueCHiP for Medicare policy for Medicare members

This policy applies to Commercial Products only. For members covered under BlueCHiP for Medicare, refer to the related Medicare policy on focal treatments for prostate cancer rather than this Commercial Products policy.

Medical criteria: Not applicable — there are no additional medical criteria specified in this policy.

Coding

Covered CPT CodesCPTCovered

55873

Cryoablate Prostate

Relevant ICD-10 CodesICD-10

C61	Malignant neoplasm of prostate
C79.82	Secondary malignant neoplasm of male genital organs
D07.5	Carcinoma in situ of prostate
Z85.46	Personal history of malignant neoplasm of prostate

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyCryoablation of Prostate Cancer

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionVerify member-specific benefits and eligibility with the provider call center and refer to subscriber/employer agreements.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Actions and Requirements

Prior Authorization

Not applicable.

Step Therapy

Step therapy / Sequencing

Cryoablation of the prostate may be considered medically necessary as initial treatment for clinically localized (organ‑confined) prostate cancer or as salvage treatment for disease that recurs following radiation therapy.

Applies to whole‑gland (total) cryoablation; focal/subtotal cryoablation considered separately in evidence review.

Note

Contract‑specific Coverage Variability

Benefits and coverage may vary between groups and contracts. Providers should verify member‑specific benefits, eligibility, and any applicable prior authorization requirements with the Blue Cross & Blue Shield of Rhode Island provider call center and review the member's Evidence of Coverage / Subscriber Agreement before delivering services.

Check Evidence of Coverage/Subscriber Agreement for Not Medically Necessary or non‑covered benefit language.
If services are non‑covered, providers may not bill members unless the member agrees in writing in advance.

Definitions

Cryoablation — definition / synonyms

Primary definitionCryoablation (also called cryotherapy or cryosurgery) — a procedure in which cryoprobes are inserted percutaneously into the prostate to rapidly freeze and thaw tissue causing necrosis.

SynonymsCryotherapy; Cryosurgery.

Technique detailsPerformed by inserting thin, needle-like cryoprobes into the prostate and delivering very cold gas down the probes to freeze and thaw tissue.

Scope — gland extentMost evidence and focus are on whole-gland (total) cryoablation; subtotal (focal) cryoablation is an emerging technique.

Policy applicabilityThis policy applies to Commercial Products only; see related Blue CHiP for Medicare policy for Medicare members.

OpenPayer

Cryoablation of Prostate Cancer

Coverage Criteria

Coding

Provider Actions and Requirements

Background

Definitions