Diagnosis: Prostate Cancer
Treatment: High intensity-focused ultrasound (HIFU) ablation
The insurer denied high intensity-focused ultrasound (HIFU) ablation.
The determination is upheld.

This is a male patient with a favorable intermediate risk prostate cancer (Gleason 3+4=7) who has requested coverage for prostate high intensity-focused ultrasound (HIFU), including ultrasound guidance. The patient's prostate-specific antigen (PSA) was 4. He is to have a transurethral resection of the prostate (TURP) 1 month prior to HIFU. He underwent a prior HIFU ablation with apparent initial success, but a recent confirmatory prostate biopsy revealed a small area of residual disease. At issue is the medical necessity of the requested high intensity-focused ultrasound (HIFU) ablation.

No. The high intensity-focused ultrasound (HIFU) ablation is not medically necessary. The patient has a favorable intermediate risk prostate cancer (Gleason 3+4=7)
Per the American Urological Association (AUA) Guidelines,
12. For patients with favorable intermediate-risk prostate cancer, clinicians should discuss active surveillance, radiation therapy, and radical prostatectomy. (Strong Recommendation; Evidence Level: Grade A)
"13. Clinicians should inform patients with intermediate-risk prostate cancer considering whole gland or focal ablation that there is a lack of high-quality data comparing ablation outcomes to radiation therapy, surgery, and active surveillance. (Expert Opinion)."