Treatment of Prostate Cancer
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Defines UHA reimbursement, medical necessity, evaluation, prior authorization, and documentation requirements for treatment of operable prostate cancer for University Health Alliance members.
No material clinical or coverage changes in this revision.
Coverage Criteria for Prostate Cancer Treatment
Coverage criteria for treatment of prostate cancer
UHA will reimburse medically necessary treatment of prostate cancer when services meet the medical criteria below and required documentation is provided.
ALL of the following
ALL of the following
- Prior authorization is required for treatment of all operable prostate cancer.
Submit requests via UHA's online portal; if no login exists, contact UHA at 808-532-4000 to establish one.
ALL of the following
- Mandatory evaluation by both a urologic surgeon and a radiation oncologist for all clinical Stage I and II patients and for clinical Stage III patients considered for prostatectomy.
Documentation from both specialists must reflect discussion of therapeutic alternatives, relative risks and benefits, and the provider's experience with the techniques contemplated. Surgeons should describe available procedures; radiation oncologists should discuss external beam therapy and brachytherapy.
ALL of the following
- Routine clinical parameters and criteria for diagnosis and staging must be met and documented.
ALL of the following
- Clinical notes describing symptoms, physical findings, and cancer staging must be included.
- Documentation evidencing evaluations by both a urologic surgeon and a radiation oncologist, consistent with the dual-specialist evaluation requirement, must be submitted.
Coding and Prior Authorization Applicability
| No codes listed |
Provider Actions and Submission Requirements
Prior authorization required for all operable prostate cancer
UHA requires prior authorization for treatment of all operable prostate cancer. To request prior authorization, submit the request via UHA's online portal; if a login has not been established, contact UHA at 808-532-4000 to establish one.
Mandatory dual-specialist evaluation and documentation
Patients in clinical Stage I and II (and clinical Stage III patients considered for prostatectomy) must be evaluated by both a urologic surgeon and a radiation oncologist, and documentation of both evaluations must be submitted; failure to provide this documentation risks denial.
- Documentation must reflect discussion of therapeutic alternatives and relative risks/benefits and the provider's personal experience with contemplated techniques.
- Clinical notes must include symptoms, physical findings, and cancer staging, plus evidence of evaluations by both specialists.
Definitions and Key Terms
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