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National Coverage Determination (NCD) for Cryosurgery of Prostate (230.9)

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Benefit Category
Inpatient Hospital Services
Outpatient Hospital Services Incident to a Physician's Service
Physicians' Services

Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Item/Service Description

Cryosurgery of the prostate gland, also known as cryosurgical ablation of the prostate (CSAP), destroys prostate tissue by applying extremely cold temperatures in order to reduce the size of the prostate gland. It is safe and effective, as well as medically necessary and appropriate, as primary treatment for patients with clinically localized prostate cancer, Stages T1-T3.


Indications and Limitations of Coverage

Cryosurgery of the prostate as a salvage therapy is not covered for any services performed prior to June 30, 2001.

Salvage Cryosurgery of Prostate After Radiation Failure. Salvage cryosurgery of the prostate for recurrent cancer is medically necessary and appropriate only for those patients with localized disease who:

  1. Have failed a trial of radiation therapy as their primary treatment; and
  2. Meet one of the following conditions: Stage T2B or below, Gleason score <9, PSA <8 ng/mL.

Cryosurgery as salvage therapy is therefore not covered under Medicare after failure of other therapies as the primary treatment. Cryosurgery as salvage is only covered after the failure of a trial of radiation therapy, under the conditions noted above.


Transmittal Number

140

Revision History

03/1997 - Provided noncoverage policy. Effective date 04/15/1997. (TN 93)

04/1999 - Allowed coverage only for primary treatment for patients with clinically localized prostate cancer, Stages T1-T3. Effective date 07/01/1999. (TN 110)

06/2001 - Expanded coverage for those patients who failed a trial of radiation treatment and met one of the limitations set forth in policy. Effective and implementation dates 07/01/2001. (TN 140) (1632)

09/2012 - CMS translated the information for this policy from ICD-9-CM/PCS to ICD-10-CM/PCS according to HIPAA standard medical data code set requirements and updated any necessary and related coding infrastructure. These updates do not expand, restrict, or alter existing coverage policy.Implementation date: 01/07/2013 Effective date: 10/1/2014. (TN 1122) (TN 1122) (CR 7818)


National Coverage Analyses (NCAs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with NCAs, from the National Coverage Analyses database.

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