Effective January 1st, 2021, the AMA has issued a category 1 CPT code for HIFU treatment (55880) which allows for Physicians, Facilities, and Anesthesiologists to bill for their respective services associated with HIFU treatment. Please check with your HIFU physician and HIFU facility to verify that they are Medicare providers. Vituro Health is not able to discuss Medicare reimbursement with patients.
Is HIFU covered by commercial insurance plans?
Currently, CIGNA is the only insurance carrier to announce coverage for High Intensity Focused Ultrasound (HIFU). However, this coverage is limited to patients who have a recurrence of prostate cancer post-radiation treatment (see coverage criteria below). All other insurers evaluate HIFU on a case by case basis and many of our patients have received reimbursement post procedure.
The Vituro Health Care Team, with assistance from the Vituro Insurance Team, will work with each patient to evaluate their policy, then assist in maximizing reimbursement. Vituro Health physicians have excellent success rates which can be a factor in reimbursement from carriers.
CIGNA HEALTH HIFU COVERAGE CRITERIA
The CIGNA policy covers HIFU as a salvage therapy for patients whose early stage prostate cancer has not metastasized and who meet both of these criteria:
- positive, recent (i.e., repeat) transrectal ultrasound guided (TRUS) biopsy completed due to suspicion of local recurrence of prostate cancer
- candidate for local therapy alone as evidenced by ALL of the following:
- original clinical stage T1-T2, NX or N0
- recent PSA (Prostate Specific Antigen) of less than 10ng/mL
- absence of distant metastases
Many patients work for large companies who are self-insured and have more flexibility with coverage versus a standard insurance product. Talk to your HR department to find out if your company is self-insured and the process you must follow to seek reimbursement. The Vituro Health Care Team will assist you in working through the benefit with your company. Vituro Health patients have seen the highest percentage of reimbursements from self-insured employers.