For dates of service beginning June 1, 2018, Harvard Pilgrim will cover cryotherapy for the treatment of prostate cancer with prior authorization for commercial members.
Cryotherapy involves freezing tumor cells in either the entire prostate gland or to localized areas where cancer is present to destroy the cells. Harvard Pilgrim considers cryotherapy medically necessary for initial treatment when documentation confirms the member has localized prostate cancer, stages T1-T3.
Salvage cryotherapy of the prostate for recurrent cancer is considered medically necessary for individuals with localized disease when documentation confirms all the following:
- Member has failed a trial of radiation therapy as their primary treatment; AND
- Member meets one of the following conditions:
- Stage T2B or below, OR
Gleason score <9, OR
- Prostate-specific antigen (PSA) <8 ng/mL
For more information, refer to Harvard Pilgrim’s updated Cryotherapy for Prostate Cancer Medical Review Criteria. To request prior authorization, please complete the Cryotherapy for Prostate Cancer Prior Authorization Request Form and fax it to 800-232-0816.