CurrentMass General Brigham Health PlanPolicy 098

High-Intensity Focused Ultrasound

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This policy describes how Mass General Brigham Health Plan determines medical necessity and prior authorization requirements for high-intensity focused ultrasound (HIFU), including MR-guided intracranial HIFU. Requirements vary by product line, and prostate cancer treatment with HIFU is considered investigational for all lines of business.

Policy Summary

PayerMass General Brigham Health Plan

PolicyHigh-Intensity Focused Ultrasound

Policy CodePolicy 098

Change TypeAnnual review and update

Effective DateOct 1, 2026

Last ReviewOct 1, 2026

Next Review DateNot specified

Key ActionObtain prior authorization for HIFU requests before treatment.

SourceLink

POLICY UPDATE CHANGES

The October 1, 2026 annual review updated the code list and the referenced Medicare LCDs and LCAs.

YesMedicare Advantage prior authorization

YesOne Care and SCO prior authorization

YesCommercial and QHP prior authorization

1Authorized intracranial procedure codes

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CurrentMass General Brigham Health PlanPolicy 098

High-Intensity Focused Ultrasound

Customize your policy alerts

Sign up for Mass General Brigham Health Plan Policy 098 alerts

Get alerted when Policy 098 changes without checking for updates manually.

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Policy Summary

PayerMass General Brigham Health Plan

PolicyHigh-Intensity Focused Ultrasound

Policy CodePolicy 098

Change TypeAnnual review and update

Effective DateOct 1, 2026

Last ReviewOct 1, 2026

Next Review DateNot specified

Key ActionObtain prior authorization for HIFU requests before treatment.

SourceLink

POLICY UPDATE CHANGES

The October 1, 2026 annual review updated the code list and the referenced Medicare LCDs and LCAs.

YesMedicare Advantage prior authorization

YesOne Care and SCO prior authorization

YesCommercial and QHP prior authorization

1Authorized intracranial procedure codes

Experimental HIFU codes

AllProstate cancer HIFU status

Medical Necessity and Coverage Pathways

Medicare Advantage Criteria Pathway

Prior authorization is required. Mass General Brigham Health Plan uses CMS guidance for Medicare Advantage medical-necessity determinations. NCDs, LCDs, LCAs, and documentation in the Medicare manuals are the basis for review.

Apply the applicable CMS coverage pathway

CMS guidance
- Apply an applicable National Coverage Determination (NCD).
- Apply an applicable Local Coverage Determination (LCD), including the CMS LCDs for MRgFUS for essential tremor and, where applicable, tremor-dominant Parkinson's disease.
- Apply an applicable Local Coverage Article (LCA) or documentation requirement in the Medicare manuals, including the CMS billing and coding articles for MRgFUS.
When CMS guidance is unavailable, apply Mass General Brigham Health Plan medical policies for medical-necessity determinations.
When an LCD is unavailable for the state in which the member seeks care, or the requested HIFU therapy is not described by the applicable LCD, apply the InterQual® criteria described in this policy.

One Care and Senior Care Options (SCO) Criteria Pathway

Prior authorization is required. Review proceeds sequentially through CMS criteria and then MassHealth criteria when CMS criteria are unavailable or not met.

Sequential review

First apply the Medicare Advantage criteria and exclusions, including applicable CMS NCDs, LCDs, LCAs, and Medicare-manual documentation.
If Medicare Advantage criteria are not met, or CMS guidance is unavailable for the requested service, apply the applicable MassHealth medical-necessity criteria.

Commercial and Qualified Health Plan Criteria

Prior authorization is required for Commercial and Qualified Health Plan members.

Commercial and Qualified Health Plan review

Medical necessity for HIFU is determined using InterQual® criteria customized by Mass General Brigham Health Plan to remove the prostate cancer treatment pathways.
Access the criteria by logging into the Mass General Brigham Health Plan provider website at MassGeneralBrighamHealthPlan.org and selecting the InterQual® Criteria Lookup link under the Resources menu.

Mass General Brigham ACO: HIFU is not a covered service for Mass General Brigham ACO members.

Prostate cancer: HIFU as a treatment for prostate cancer is experimental and investigational for all lines of business. This includes treatment represented by CPT code 55880. The codes listed in this policy are provided for informational purposes only; inclusion of a code does not constitute or imply coverage or reimbursement. CPT code 61715 describes MRgFUS stereotactic ablation of an intracranial target, including stereotactic navigation and frame placement when performed.

HIFU for prostate cancer remains investigational because high-quality, long-term evidence supporting oncologic efficacy and safety compared with established treatments is limited. Although HIFU may offer favorable functional outcomes, uncertainty remains regarding cancer recurrence, incomplete treatment, patient selection, standardized protocols, and long-term follow-up. Guidelines and evidence reviews, including those from the German S3, European Association of Urology, and National Comprehensive Cancer Network, describe less certain oncologic control and generally reserve HIFU for investigational use or salvage therapy in recurrent disease rather than as frontline standard treatment for localized prostate cancer. The FDA has approved HIFU for destruction of prostate tissue but has not explicitly approved it for treatment of prostate cancer; the limited evidence, lack of consistent professional-society support, and absence of such FDA approval support the Plan's investigational determination for all lines of business.

Covered and Experimental Codes

Authorized CodeCPTCovered

61715

Magnetic resonance image guided high intensity focused ultrasound (MRgFUS), stereotactic ablation of target, intracranial, including stereotactic navigation and frame placement, when performed

Experimental and InvestigationalCPTExperimental

55880

Authorization and Billing Guidance

Prior Authorization

Medicare Advantage: Prior Authorization Required

Prior authorization is required for HIFU for Mass General Brigham Health Plan Medicare Advantage members. Medical-necessity determinations use applicable CMS National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Local Coverage Articles (LCAs), and Medicare-manual documentation; when CMS guidance is unavailable, the Plan’s medical policies apply.

Applicable CMS guidance includes LCD L38506, LCD L38495, and LCD L37729 for MRgFUS for essential tremor and, where applicable, tremor-dominant Parkinson’s disease.
Applicable CMS billing and coding articles include A57884, A57839, and A57512.
Submit the documentation required by the applicable CMS coverage guidance with the prior-authorization request.

Prior Authorization

One Care and SCO: Sequential Review Required

Prior authorization is required for One Care and Senior Care Options (SCO) members. Apply Medicare Advantage criteria first; if CMS guidance is unavailable or the member does not meet all Medicare medical-necessity criteria, apply MassHealth criteria sequentially.

High-Intensity Focused Ultrasound Overview

High-intensity focused ultrasound (HIFU) uses focused ultrasound energy to ablate a targeted area. When performed with magnetic-resonance guidance and stereotactic navigation, it can target intracranial structures as MR-guided focused ultrasound (MRgFUS). The policy references MRgFUS for essential tremor and Parkinson’s disease, subject to applicable coverage criteria.

Policy Summary

PayerMass General Brigham Health Plan

PolicyHigh-Intensity Focused Ultrasound

Policy CodePolicy 098

Change TypeAnnual review and update

Effective DateOct 1, 2026

Last ReviewOct 1, 2026

Next Review DateNot specified

Key ActionObtain prior authorization for HIFU requests before treatment.

SourceLink

On This Page

Use applicable NCDs, LCDs, LCAs, and Medicare-manual documentation as the initial review basis.
If Medicare Advantage criteria are not met, MassHealth medical-necessity criteria are applied.

Prior Authorization

Commercial and QHP: Prior Authorization Required

Prior authorization is required for Commercial and Qualified Health Plan members. Medical necessity is determined using Mass General Brigham Health Plan’s customized InterQual® criteria, which exclude prostate cancer treatment pathways.

Access the criteria by logging into MassGeneralBrighamHealthPlan.org and selecting the InterQual® Criteria Lookup link under the Resources menu.
Submit clinical documentation supporting the applicable InterQual® criteria with the authorization request.

Denial Risk

Mass General Brigham ACO: Not Covered

HIFU is not a covered service for Mass General Brigham ACO members.

Do not expect coverage or reimbursement for HIFU for Mass General Brigham ACO members.

Billing Rule

Experimental Code: 55880

Code 55880 is experimental and investigational for all lines of business. Code inclusion does not constitute or imply coverage or reimbursement.

55880 — Experimental and investigational for all lines of business.
61715 — Magnetic resonance image guided high-intensity focused ultrasound (MRgFUS), stereotactic ablation of target, intracranial, including stereotactic navigation and frame placement, when performed; included for informational purposes only.

Denial Risk

Prostate Cancer HIFU: Experimental and Investigational

HIFU as a treatment for prostate cancer is experimental and investigational for all lines of business because high-quality long-term evidence supporting oncologic efficacy and safety compared with established treatments remains limited.

Do not submit prostate cancer HIFU as a covered standard treatment.
The Plan’s position reflects limited evidence, uncertain oncologic control, lack of consensus on patient selection and standardized protocols, limited long-term follow-up, and the absence of explicit FDA approval for HIFU as a prostate cancer treatment.
Leading guidelines and expert consensus generally reserve HIFU for investigational use or salvage therapy in recurrent disease rather than frontline treatment for localized prostate cancer.

Documentation Required

Applicable Medicare Coverage Criteria

For members receiving care in states not covered by the cited LCDs, or for HIFU therapies not described in those LCDs, Mass General Brigham Health Plan applies additional medical-necessity criteria. The Plan uses the InterQual® criteria described in this policy, which are intended to align with current clinical evidence and accepted standards of practice.

If an applicable CMS NCD is unavailable, use the Plan’s additional coverage criteria to clarify medical necessity, documentation requirements, and clinical indications.
Refer to the Commercial and Qualified Health Plan section for the applicable medical-necessity information.
Do not rely on the cited LCDs when the member’s care location or requested HIFU therapy falls outside their scope.