Urology Coding Alert

Question: I have heard the NGS has made some recent policy decisions about prostate cancer treatments. What updates do we need to know about?

New York Subscriber

Answer: You are correct that National Government Services (NGS), the Part B Medicare contractor for Connecticut, Illinois, Maine, Massachusetts, Minnesota, New Hampshire, New York, Rhode Island, Vermont, and Wisconsin, has recently published an update that could affect your urology practice.

On Oct. 27, NGS published a news article announcing retirement of proposed local coverage determination (LCD) DL38262, titled Salvage High-intensity Focused Ultrasound (HIFU) Treatment in Prostate Cancer (PCa), based on comments NGS received during its Oct. 20 Open Meeting.

According to three commentors in the Open Meeting, the LCD did not allow appropriate coverage of this procedure for patients with prostate cancer. The first commentor, Derek Lomas, MD, assistant professor of urology at Mayo Clinic in Rochester, Minn., stated “Medicare patients in our region seeking HIFU for primary treatment of prostate cancer are denied coverage for the procedure, due to this current determination.”

Thomas Frye, DO, associate professor of urology at the University of Rochester in New York, echoed those thoughts, stating: “I think the real question is ‘Where does primary HIFU fit within the proposed salvage LCD?’, and it really doesn’t. And my patients that I see with localized prostate cancer, who would be good candidates for this, are limited because the current language limits it to patients who’ve only had salvage therapy. And it’s not systematically covered around the U.S., where some of my colleagues … in different jurisdiction are allowed to get this treated.”

Final commentor David Silver, MD, urologic oncologist and chief of urology at Maimonides Medical Center in Brooklyn, N.Y., summed things up saying, “NGS policy limiting prostate HIFU ablation to the salvage setting is outdated, out of step with other MACs [Medicare Administrative Contractors], out of line with the latest guidelines, and simply unfair to patients.”

Resources: You can read the retired LCD policy on the NGS website at https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=38262&ver=5&bc=0. You can listen to the Open Meeting recording here: https://www.ngsmedicare.com/web/ngs/lcd-open-meeting?selectedArticleId=1945845&lob=93618&state=97184&region=93624.