Reimbursement Expanded for Focused Ultrasound Treatment of Prostate Cancer


CMS logoFocused ultrasound therapy for patients with prostate cancer that has not responded to prior radiation treatment may now be covered in some US states.

National Government Services, Inc. (NGS) has announced coverage – in effect for procedures performed on or after April 1, 2020 – for focused ultrasound as a salvage therapy for prostate cancer. NGS has beneficiaries in Connecticut, Illinois, Maine, Minnesota, New Hampshire, New York, Rhode Island, Vermont, and Wisconsin.

The coverage announcement includes distinct codes for whole gland treatment procedures performed using three common focused ultrasound devices: Sonablate (SonaCare Medical), Ablatherm (EDAP TMS), and Focal One (EDAP TMS).

Patients eligible for NGS coverage must have a current prostate cancer diagnosis and rising prostate-specific antigen (PSA) levels after prior radiation therapy treatment.

In 2015, focused ultrasound earned US Food and Drug Administration (FDA) approval for the ablation of prostate tissue. This ruling enabled physicians to treat conditions such as prostate cancer and benign prostatic hyperplasia (BPH).

Private insurance coverage for focused ultrasound treatment of prostate cancer began in July 2017 and now includes Asuris Northwest Health (Washington), BCBS Michigan, Blue Shield Regence (Idaho, Oregon, Utah, and Washington), CIGNA (all states) and HAP Health Alliance Plan (Michigan). With the recent NGS ruling, there are now 22.8 million beneficiaries covered.

Patients who are interested in taking advantage of this coverage should contact their physician to ensure that they qualify. More information is available here.