Currentpriority healthPolicy 91601

HIGH INTENSITY FOCUSED ULTRASOUND

Defines medical necessity, investigational uses, and coverage guidance for HIFU and MRgFUS across multiple indications, and applies to Priority Health members subject to plan benefits.

Policy Summary

Payerpriority health

PolicyHIGH INTENSITY FOCUSED ULTRASOUND

Policy CodePolicy 91601

Change TypeUpdated references

Effective DateJun 1, 2026

Next Review Date

Key ActionSubmit prior authorization demonstrating medical necessity and consult InterQual/EviCore/TurningPoint criteria via Priority Health Prism when requesting HIFU/MRgFUS.

SourceLink

POLICY UPDATE CHANGES

Updated references

2Medically necessary indications (when InterQual met)

13Experimental/investigational indications

07/25/2016ExAblate Neuro FDA approval

2Procedure CPT codes listed

3Example ICD-10 supportive codes

Coverage Criteria

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Medical Necessity and Investigational Indications

MRgFUS Medically Necessary Indications: Magnetic resonance-guided focused ultrasound (MRgFUS) is medically necessary when InterQual criteria are met for: 1) medication-refractory essential tremor; 2) medication-refractory, tremor-dominant Parkinson's disease.InterQual criteria

HIFU Experimental/Investigational Indications: HIFU (including MRgFUS when used for these indications) is experimental and investigational due to insufficient evidence of long-term effectiveness for: 1) atrial fibrillation; 2) benign prostatic hypertrophy; 3) central nervous system diseases/disorders (e.g., brain cancer and stroke); 4) fractures; 5) liver metastasis from colon and stomach cancer; 6) osteosarcoma/bone tumors; 7) palliation of bone metastases; 8) pancreatic cancer; 9) primary liver cancer; 10) prostate cancer as primary therapy; 11) renal cancer; 12) thyroid nodules; 13) vulvar dystrophy.

Numbered list in policy

HIFU as secondary local therapy for recurrent prostate cancer after definitive radiotherapy, in the absence of metastatic disease, may be medically necessary according to NCCN guidelines.NCCN guidelines

The following CPT and unlisted procedure codes are designated Not Medically Necessary when billed for the services listed: 0950T, 27599, 47399, 48999, 50549, 55899, 58999, 60699, 64999, and 76999. When any of these unlisted codes are billed, explanatory notes must accompany the claim describing the procedure and rationale for the service.

This portion of the policy does not list any explicit coverage exclusions beyond the coding and not medically necessary designations already provided; recent updates are limited to reference clarifications and committee review dates.

High-intensity focused ultrasound (HIFU) and magnetic resonance-guided focused ultrasound (MRgFUS) are addressed separately by indication. MRgFUS is medically necessary when InterQual criteria are met for (1) medication-refractory essential tremor and (2) medication-refractory, tremor-dominant Parkinson disease. HIFU (including MRgFUS when used for the same applications listed below) is considered experimental and investigational for a range of conditions due to insufficient evidence of long-term effectiveness; these include atrial fibrillation, benign prostatic hypertrophy, central nervous system diseases/disorders (e.g., brain cancer and stroke), fractures, liver metastasis from colon and stomach cancer, osteosarcoma/bone tumors, palliation of bone metastases, pancreatic cancer, primary liver cancer, prostate cancer as primary therapy, renal cancer, thyroid nodules, and vulvar dystrophy. Additionally, HIFU as secondary local therapy for recurrent prostate cancer after definitive radiotherapy may be medically necessary per NCCN guidelines in the absence of metastatic disease.

There are no additional explicit not medically necessary determinations stated in this section beyond the investigational indications and the coding denials noted elsewhere in the policy; the recent summary of changes reflects only updated references.

Coding and Billing

Covered CPT CodesCPTCovered

55880	Ablation of malignant prostate tissue, transrectal, with high intensity- focused ultrasound (HIFU), including ultrasound guidance
61715	Magnetic resonance image guided high intensity focused ultrasound (MRgFUS), stereotactic ablation of target, intracranial, including stereotactic navigation and frame placement, when performed

Not Medically Necessary / Unlisted CodesCPTNot Covered

0950T	Ablation of benign prostate tissue, transrectal, with high intensity-focused ultrasound (HIFU), including ultrasound guidance
27599	Unlisted procedure, femur or knee
47399	Unlisted procedure, liver
48999	Unlisted procedure, pancreas
50549	Unlisted laparoscopy procedure, renal
55899	Unlisted procedure, male genital system [ when specified as destruction of prostate tissue by high intensity focused ultrasound ]
58999	Unlisted procedure, female genital system (non-obstetrical)
60699	Unlisted procedure, endocrine system
64999	Unlisted procedure, nervous system
76999	Unlisted ultrasound procedure (eg, diagnostic, interventional) - Explanatory notes must accompany claims billed with unlisted codes

ICD-10 Codes that may support medical necessityICD-10

C61	Malignant neoplasm of prostate
R97.21	Rising PSA following treatment for malignant neoplasm of prostate
Z92.3	Personal history of irradiation

Provider Actions and Authorization

Prior Authorization

Prior Authorization — HIFU/MRgFUS

Prior authorization may be required for HIFU/MRgFUS. Providers must submit a prior authorization request when required and demonstrate medical necessity. Refer to Priority Health Provider Manual and Priority Health Prism for authorization criteria and to the listed external guideline sources (EviCore, InterQual, TurningPoint) for specific clinical criteria.

When prior authorization is required, submit documentation showing medical necessity per the referenced clinical guideline (EviCore, InterQual, TurningPoint).
Use Priority Health Prism: Authorizations → Authorization Criteria Lookup to locate relevant guideline criteria.

Denial Risk

Not Medically Necessary Codes / Denial Triggers

Claims billed with unlisted CPT codes or specific listed codes in this policy that are designated Not Medically Necessary will be subject to denial. Explanatory notes must accompany claims billed with unlisted codes.

0950T — Ablation of benign prostate tissue, transrectal, with HIFU.
Unlisted procedure codes (27599, 47399, 48999, 50549, 55899, 58999, 60699, 64999, 76999) — explanatory notes required with claims.

Note

Provider Actions — Additional Notes

This section does not contain additional provider action items beyond prior authorization guidance and coding/denial information noted above. Providers should follow the Priority Health Provider Manual and use Priority Health Prism for authorization lookups.

Definitions

HIFU — High-intensity focused ultrasound (HIFU)

TermHigh-intensity focused ultrasound (HIFU)

DefinitionUses externally generated sonic waves to create a sharply delineated area of thermal energy that destroys target tissue by rapid temperature elevation.

Clinical uses noted in policySalvage treatment for localized recurrence of prostate cancer after external beam radiotherapy or radical prostatectomy; can ablate entire gland or focal cancer-containing portion.

Evidence summaryClinical studies and registry analyses report short- to medium-term local control and progression-free survival for focal and salvage HIFU, but long-term effectiveness as an alternative to radical prostatectomy or radiation remains uncertain.

MRgFUS — Magnetic resonance-guided focused ultrasound (MRgFUS)

TermMagnetic resonance-guided focused ultrasound (MRgFUS)

DefinitionMR imaging and thermal mapping guide transcranial focused ultrasound thalamotomy that targets and ablates portions of the thalamus (typically the ventral intermediate nucleus, VIM) in an incisionless procedure.

Regulatory noteExAblate Neuro (Insightec) received FDA approval for MRgFUS thalamotomy (original approval 07/25/2016 with subsequent supplements).

HIFU / MR-guided focused ultrasound — Focused ultrasound technologies referenced include transrectal HIFU for prostate cancer and transcranial MR-guided focused ultrasound for...

Scope of technologiesIncludes transrectal HIFU for focal or whole-gland prostate ablation and transcranial MR-guided focused ultrasound for thalamotomy (e.g., ExAblate Neuro).

Supporting sourcesGuidelines and HTAs cited include AAN, NICE, Hayes, Health Quality Ontario, NCI, and multiple systematic reviews and clinical studies.

Clinical contextMRgFUS is incisionless and guided by MRI/thermal mapping for targeted thalamotomy; HIFU delivers focused sonic waves for thermal ablation, applied in trials for prostate salvage and focal therapy.

OpenPayer

HIGH INTENSITY FOCUSED ULTRASOUND

Coverage Criteria

Coding and Billing

Provider Actions and Authorization

Background

Definitions