CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Saturation Biopsy for Diagnosis, Staging and Management of Prostate Cancer

Policy governing coverage determinations for saturation prostate biopsy (more than 20 cores) for diagnosis, staging, and management of prostate cancer for BCBSRI members across product lines.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicySaturation Biopsy for Diagnosis, Staging and Management of Prostate Cancer

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2015

Next Review DateN/A

Key ActionDo not file claims for CPT 55706 for Medicare Advantage and consider CPT 55706 not medically necessary for commercial products; do not bill saturation biopsy with 55700 or G0416.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>20definition of saturation biopsy

55706CPT code not covered

2013systematic review year

09|04|2024last reviewed

Coverage Criteria

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicySaturation Biopsy for Diagnosis, Staging and Management of Prostate Cancer

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2015

Next Review DateN/A

Key ActionDo not file claims for CPT 55706 for Medicare Advantage and consider CPT 55706 not medically necessary for commercial products; do not bill saturation biopsy with 55700 or G0416.

SourceLink

On This Page

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Medicare Advantage: Saturation biopsy is not covered in the diagnosis, staging, and management of prostate cancer as the evidence is insufficient to determine that the technology results in an improvement in the net health outcomes.

Commercial Products: Saturation biopsy is considered not medically necessary in the diagnosis, staging, and management of prostate cancer as the evidence is insufficient to determine that the technology results in an improvement in the net health outcomes.

The CPT code 55706 ("Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidance") is identified in this policy as not covered for Medicare Advantage and not medically necessary for Commercial Products. Providers should not submit claims for saturation sampling using 55700 or G0416, as those codes are not specific to saturation biopsy and are not appropriate for reporting this procedure.

Provider Actions & Billing Guidance

Note

Prior Authorization

Prior authorization is not applicable for this policy.

Note

Provider Action

Documentation Required

Benefit Verification

Benefits may vary between groups and contracts. Providers must verify member-specific benefits and eligibility by referring to the member's Benefit Booklet, Evidence of Coverage (EOC), Subscriber Agreement, or by contacting the provider call center before performing services.

Check the member's Benefit Booklet / Evidence of Coverage / Subscriber Agreement for applicable coverage or benefit limitations
Contact the provider call center for member-specific benefit and eligibility confirmation

Billing Rule

Noncoverage and Claim Filing Guidance

Coding and claim filing guidance: Saturation biopsy (CPT 55706) is not covered for Medicare Advantage Plans and is considered not medically necessary for Commercial Products. When performing saturation biopsy, do not bill codes 55700 or G0416 for the saturation sampling procedure, as they are not specific to saturation sampling.

Not covered / Not medically necessary code: 55706 — Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidance
Do NOT file claims for saturation biopsy using CPT 55700 or G0416

Background

Saturation prostate biopsy refers to sampling the prostate with a large number of cores—generally more than 20 cores—to improve detection by better sampling anterior zones. It may be performed via the transrectal route or via a transperineal, stereotactic template-guided approach. Although saturation techniques increase tissue sampling, current evidence has not shown that they improve net health outcomes; accordingly, the policy designates stereotactic template-guided saturation sampling (CPT 55706) as not covered or not medically necessary across product lines.

Definitions

Definition — Saturation prostate biopsy

Core count threshold>20 cores (saturation biopsy is generally considered more than 20 cores)

Sampling purposeImproved sampling of anterior zones of the prostate which may be under-sampled by standard peripheral zone strategies

ApproachesCan be performed transrectally or transperineally

Transperineal technique detailTransperineal saturation biopsy is generally stereotactic template-guided and performed under general anesthesia

Relation to extended biopsySaturation biopsy obtains substantially more cores than the common 12–14 core extended biopsy to increase cancer detection

55700	Biopsy, prostate; needle or punch, single or multiple, any approach
G0416	Prostate biopsy, transrectal, with or without ultrasound guidance; guidance statement (code noted as not specific to saturation sampling)