HIFU Proposal

Decent Essays
A review of the records reveals the member to be an adult male with a birth date of 08/28/1964. The member has a diagnosis of prostate cancer. The member’s treating provider, Gregory Haselhuhn, MD has requested an out of plan referral to urologist Herb Riemenschneider for High Intensity Focused Ultrasound (HIFU).

The carrier has denied coverage of HIFU as not medically necessary. There is a letter from the carrier to the member dated 01/18/2016, which states in part:

“Your request for an Appeal regarding Paramount’s denial of an Out of Plan referral was denied. The Associate Medical Director denied the request for a second opinion as there is In Plan Urologist available; the FDA has very recently approved this procedure for prostate
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It is up to the doctor to decide what tissue is to be treated and why. As the enclosed articles will substantiate that the FDA has in fact cleared non invasive HIFU treatment for prostate cancer. HIFU treatments for early stage prostate cancer is now considered the standard of care in most European Countries and Canada, with an efficacy rate that is superior to the outdated methods being currently employed by in plan urologists. If there was an in-plan urologist that was qualified and trained in this procedure, I would gladly stay in plan, but as this is not the case at present, it is necessary to go to an out of plan urologist for a second opinion in order to determine a correct and effective and up to date treatment for my diagnosed condition.”

Final External Review Decision:

The carrier’s decision to deny coverage for a second opinion with an Out of Plan referral to Dr. Herb Riemenschneider at Riverside Urology for High Intensity Focused Ultrasound provider was appropriate.

The use of High Intensity Focused Ultrasound for the treatment of prostate cancer is considered experimental and/or
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