TN 10 (01-14)

DI 23022.282 Prostate Cancer - Hormone Refractory Disease – or with Visceral Metastases

COMPASSIONATE ALLOWANCE INFORMATION

PROSTATE CANCER- HORMONE REFRACTORY DISEASE

ALTERNATE NAMES

Jewett Stage D2 Prostate Cancer; Stage D2 Metastatic Prostate Cancer; Hormone Refractory Metastatic Prostate Cancer; Metastatic Castration-Resistant Prostate Cancer

DESCRIPTION

Prostate Cancer – Hormone Refractory Disease occurs when the cancer is recurrent (comes back despite hormonal intervention) or the cancer has spread to the bone or visceral organs (visceral metastases) such as the liver and lungs.

DIAGNOSTIC TESTING, PHYSICAL FINDINGS, AND ICD-9-CM CODING

Diagnostic testing: The diagnosis of prostate cancer requires a biopsy, and the most common method is by fine needle biopsy of a prostate mass. Screening tools include digital rectal examination (DRE), Prostate Specific Antigen (PSA) blood test, and transrectal (TRUS) ultrasound. Staging of the cancer is based on the results of the biopsy, as well as, imaging studies such as radionuclide bone scans, computerized tomography (CT), Magnetic Resonance Imaging (MRI), and ProstaScint Scan; lymph node biopsy; or laparoscopic biopsy.

Physical findings: Advanced stages of prostate cancer can include findings related to organs or tissues where the cancer has spread. Symptoms of such spread may include blood in the urine; impotence; pain in the hips, back (spine), or chest (ribs); weakness or numbness in the legs or feet; and loss of bladder or bowel control.

ICD-9: 185

ONSET AND PROGRESSION

The overwhelming majority of prostate cancers are diagnosed early and have an extremely high long-term survival rate. For those cancers diagnosed after the cancer has spread, the survival rate is much lower.

TREATMENT

The treatment for prostate cancer –hormone refractory disease depends on the age of the patient at diagnosis, coexisting medical illnesses, symptoms, and the presence of distant metastases. The most common treatment for prostate cancer- hormone refractory disease is a combination of hormone therapy (chemical castration) and external beam radiation therapy (EBRT).

SUGGESTED PROGRAMMATIC ASSESSMENT*

Suggested MER for evaluation:

  • Clinical history and examination that describes the diagnostic features of the impairment.

  • Pathology report of biopsy findings.

  • Treatment notes indicating antineoplastic therapy.

  • Surgery or imaging reports that document the spread or recurrence of prostate cancer.

Suggested Listings for Evaluation:

DETERMINATION

LISTING

REMARKS

Meets Listing

13.24 A or B

Listing-level criteria requires Prostate Cancer to be either: metastatic (Stage IV) to lung, liver, or other internal visceral organ (excluding bone metastases); or progressive or recurrent despite initial hormonal therapy. Prostate Cancer with visceral metastases meets listing 13.24B

Equals Listing

  

* Adjudicators may, at their discretion, use the Medical Evidence of Record or Listings suggested to evaluate the claim. However, the decision to allow or deny the claim rests with the adjudicator.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0423022282
DI 23022.282 - Prostate Cancer - Hormone Refractory Disease - or with Visceral Metastases - 01/10/2014
Batch run: 01/10/2014
Rev:01/10/2014