Program Operations Manual System (POMS)
TN 60 (10-23)
DI 23022.282 Prostate Cancer – Hormone Refractory Disease – or with Visceral Metastases
COMPASSIONATE ALLOWANCES INFORMATION
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PROSTATE CANCER - HORMONE REFRACTORY
DISEASE - OR WITH
VISCERAL METASTASES
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ALTERNATE NAMES
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Jewett Stage D2 Prostate Cancer; Stage D2 Metastatic Prostate Cancer; Hormone Refractory
Metastatic Prostate Cancer; Metastatic Castration-Resistant Prostate Cancer
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DESCRIPTION
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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.
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DIAGNOSTIC TESTING, PHYSICAL FINDINGS, AND ICD-9-CM/ICD-10-CM CODING
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Diagnostic testing: The diagnosis and staging of prostate cancer requires:
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Fine needle biopsy of a prostate mass;
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Digital rectal examination (DRE);
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Prostate Specific Antigen (PSA) blood test;
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Transrectal (TRUS) ultrasound;
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Computerized tomography (CT scan);
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Magnetic Resonance Imaging (MRI);
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Physical findings: People with advanced prostate cancer-hormone refractory disease may present with:
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Pain in the hips, back (spine), or chest (ribs);
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Weakness or numbness in the legs or feet; and
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Loss of bladder or bowel control.
ICD-9: 185
ICD-10: C61
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PROGRESSION
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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.
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TREATMENT
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The initial anticancer treatment for prostate cancer usually is –hormone therapy (for
example, androgen). Refractory disease occurs when prostate cancer no longer responds
to hormone therapy (that is, androgen-independent disease). Treatments for hormone
refractory prostate cancer includeis chemotherapy, adrenal suppressants,immunotherapy
drugs, and external beam radiation therapy (EBRT).
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SUGGESTED PROGRAMMATIC ASSESSMENT*
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Suggested MER for
Evaluation:
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Clinical history and examination that describes the diagnostic features of the impairment;
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Pathology report of biopsy findings;
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Treatment notes indicating antineoplastic therapy; and
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Surgery or imaging reports that document the spread or recurrence of prostate cancer.
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Suggested Listings for Evaluation:
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DETERMINATION
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LISTING
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REMARKS
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Meets
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13.24 A or B
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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 the criteria in listing 13.24 B.
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Equals
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* 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.
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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 - 10/05/2023
Batch run: 10/05/2023
Rev:10/05/2023 |