CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Focal therapy (including focal laser ablation) for localized prostate cancer

This policy governs coverage and medical necessity determinations for use of focal therapy modalities (including focal laser ablation) to treat localized prostate cancer for Blue Cross Blue Shield - Rhode Island products, specifying stances for Medicare (BlueCHiP) and Commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyFocal therapy (including focal laser ablation) for localized prostate cancer

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 10, 2015

Next Review DateN/A

Key ActionDo not bill HCPCS C9747; use unlisted procedure code 55899 for focal therapy billing and verify member benefits with the benefit booklet or provider call center.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not coveredBlueCHiP stance

Not medically necessaryCommercial stance

55899Billing code

C9747Specific code not covered

Insufficient evidencePrimary reason

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.

Coverage Determinations

Coverage stance for focal therapy modalities

Policy coverage determinations for focal therapy modalities in localized prostate cancer:

BlueCHiP for Medicare: Use of any focal therapy modality to treat patients with localized prostate cancer is not covered because the evidence is insufficient to determine effects on health outcomes.

Commercial Products: Use of any focal therapy modality to treat patients with localized prostate cancer is not medically necessary because the evidence is insufficient to determine effects on health outcomes.

The HCPCS code C9747 ("Ablation of prostate, transrectal, high intensity focused ultrasound (HIFU), including imaging guidance") is explicitly designated in this policy as not covered for BlueCHiP for Medicare and not medically necessary for Commercial products.

Benefits and eligibility for members are determined by the member's subscriber agreement, member certificate, or employer agreement, which supersede this medical policy; for member-specific benefits, contact the provider call center. This policy is informational and is not a guarantee of payment.

This policy addresses focal therapy modalities used to treat localized prostate cancer, including but not limited to focal laser ablation, high‑intensity focused ultrasound (HIFU), cryoablation, radiofrequency ablation (RFA), and photodynamic therapy. The evidence base is limited, heterogeneous, and primarily observational, and no prospective comparative trials versus standard treatments (radical prostatectomy, external‑beam radiotherapy, or active surveillance) have been identified. As noted under coding, there is no specific CPT code for these procedures; billing for focal therapy should use the unlisted male genital system code 55899, and do not bill the HIFU HCPCS code C9747 which is not covered/not medically necessary.

Billing and Coding

Unlisted CPT Codes (use for focal therapy)CPT

55899

Unlisted procedure, male genital system

Not covered / Not medically necessary codeHCPCSNot Covered

C9747

Ablation of prostate, transrectal, high intensity focused ultrasound (HIFU), including imaging guidance

Provider Requirements & Billing Impact

Prior Authorization

Not applicable.

Note

Benefit Verification

Benefits may vary between groups and contracts. Confirm member-specific benefits and coverage by reviewing the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement or by contacting the provider call center.

Verify eligibility and benefits prior to providing services.
Contact the provider call center for member-specific coverage information.

Clinical Background

Focal therapy is intended to selectively ablate the index lesion or other targeted cancerous lesions within the prostate with the goal of minimizing treatment‑related morbidity compared with whole‑gland radical therapies. Rationale for focal approaches includes reducing urinary, sexual, and bowel adverse effects associated with radical prostatectomy or radiotherapy while treating clinically significant disease. However, limitations in lesion localization, variable reporting, short follow‑up, and lack of standardized methods for selecting which lesions to treat contribute to uncertainty about long‑term oncologic outcomes and functional benefits.

Key Definitions

Index lesion definition — largest lesion driving natural history

DefinitionThe index lesion is the largest cancerous lesion with the highest grade tumor thought to drive the natural history of typically multifocal prostate cancer and is the primary target for lesion‑targeted focal therapy.

Clinical rationalePathologic and molecular evidence suggests a single index tumor focus usually determines progression and metastasis, justifying targeted treatment of this lesion.

Lesion selection implicationLesion‑targeted focal therapy treats the index lesion while leaving small (<0.5 cm) low‑grade foci in place, preserving options for subsequent definitive therapy if needed.

Role in focal therapy planningIdentification of the index lesion is critical for oncologic success and guides both planning and delivery of focal ablation energy.

Transperineal template mapping (TPM) biopsy definition and characteristics

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyFocal therapy (including focal laser ablation) for localized prostate cancer

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 10, 2015

Next Review DateN/A

Key ActionDo not bill HCPCS C9747; use unlisted procedure code 55899 for focal therapy billing and verify member benefits with the benefit booklet or provider call center.

SourceLink

On This Page

Billing documentation note

Use the unlisted procedure code for billing; do not bill C9747. Document clinical indication and procedure details in the medical record to support the use of 55899.

Bill with 55899 — Unlisted procedure, male genital system.
C9747 is not covered for BlueCHiP for Medicare and is considered not medically necessary for Commercial Products.

Denial Risk

Member financial liability if service is not medically necessary or not covered

Use of any focal therapy modality to treat localized prostate cancer is not covered for BlueCHiP for Medicare and is considered not medically necessary for Commercial Products. If services are determined to be not medically necessary or are non-covered benefits, providers may not bill the member unless the member was informed in advance and agreed in writing to pay out-of-pocket as allowed by the participation/contract documents.

BlueCHiP for Medicare: not covered.
Commercial Products: not medically necessary.
Providers may only collect member payment for NMN or non-covered services when the member has provided prior written agreement as allowed by contract.

Transperineal template mapping (TPM) biopsy is a systematic 5 mm transperineal prostate biopsy performed using a brachytherapy template that provides 3‑dimensional coordinates of cancerous lesions.

AccuracyTPM has reported accuracy rates of approximately 87% to 95% for detecting and ruling out clinically significant prostate cancer.

Resource and procedural considerationsTPM is resource‑intensive, requires general anesthesia, and involves processing multiple biopsy specimens, limiting practicality and widespread use.

Adverse eventsReported adverse events include urinary retention (~6%), prostatitis (~4%), and local perineal events such as hematoma, bruising, or pain (~5%).

Multiparametric MRI (mp‑MRI) definition and components (T1, T2, DWI, DCE)

DefinitionMultiparametric MRI (mp‑MRI) typically includes T1, T2, diffusion‑weighted imaging (DWI), and dynamic contrast‑enhanced (DCE) imaging to detect and risk‑stratify prostate lesions.

Performance versus TPMWith TPM as the reference standard for lesions ≥4 mm and Gleason ≥3+4, mp‑MRI sensitivity was 58%–73% and negative predictive value 84%–89%, suggesting reasonable ability to rule out clinically significant cancer.

Limitationsmp‑MRI requires specialized MRI‑compatible equipment, experienced uroradiologists for interpretation, and histologic confirmation of suspicious lesions (eg, via TPM).

Clinical usemp‑MRI can detect high‑grade, larger prostate cancer foci and is a promising modality to select patients and lesions for focal therapy, but constraints limit widespread use.