TN 20 (12-18)

DI 23022.345 Ureter Cancer

COMPASSIONATE ALLOWANCE INFORMATION

URETER CANCER

ALTERNATE NAMES

Metastatic Transitional Cell Carcinoma of the Ureter (Stage IV); Squamous Cell Cancer of the Ureter; Squamous Cell Carcinoma of the Ureter; Adenocarcinoma of the Ureter; Ureter Carcinoma

DESCRIPTION

Ureter Cancer forms in transitional cells in the lining of the bladder, ureter, or renal pelvis. Transitional cells are cells that can change shape and stretch without breaking apart. Misuse of certain pain medications can affect the risk of developing transitional cell cancer of the renal pelvis or ureter.

Risk factors can include prolonged misuse of certain pain medications, smoking cigarettes, exposure to certain dyes and chemicals used in making leather goods, textiles, plastics, or rubber.

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

Diagnostic testing: The following tests may be used to diagnose the disease: physical exam and history, urinalysis, ureteroscopy, urine cytology, intravenous pyelogram (IVP), CT scan, and/or ultrasound.

Physical findings: Symptoms may include:

  • Blood in the urine;

  • Persistent back pain;

  • Extreme fatigue;

  • Unintentional weight loss; and/or

  • Painful or frequent urination.

ICD-9: 189.2

PROGRESSION

Ureter Cancer usually affects men more often than women and is more common in people older than 65. The 5-year survival rate is 5% or less.

TREATMENT

If the cancer is inoperable or unresectable, treatment with radiation and/or chemotherapy may be utilized for palliation, but the prognosis is poor.

SUGGESTED PROGRAMMATIC ASSESSMENT*
Suggested MER for Evaluation:
  • A pathology report and an operative report are the preferred methods for documentation.

  • Clinical note from a surgeon that the cancer is inoperable or unresectable.

  • Surgical pathology report that the cancer was not completely removed and that the surgical margins were positive for malignancy.

  • In the absence of these reports, the adjudicator may use a physician's opinion that indicates the cancer is inoperable or unresectable based on described objective findings.

“Inoperable” refers to a physician's opinion that surgery would not be beneficial based on a review of imaging studies, laboratory results, and physical examination findings.“Unresectable” cancer is established when the operative report indicates that the cancer is not completely removed or the pathology report notes that the surgical specimen has positive margins.
DETERMINATION

LISTING

REMARKS
Meets 13.21 A or B Ureter Cancer that is inoperable, unresectable, recurrent, or with metastases meets13meets 13.21 A or B.
Equals
* Adjudicators may, at their discretion, use the Medical Evidence of Record or the 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/0423022345
DI 23022.345 - Ureter Cancer - 12/13/2018
Batch run: 12/13/2018
Rev:12/13/2018