Transperineal Placement of Biodegradable Material for Prostate Cancer (CPB 0926, reviewed 2025-12-23)

By January 6, 2026: Billing team must update claim submission logic in billing software to implement the following rules: (1) CPT 55874 is COVERED ONLY when billed with ICD-10 diagnosis C61 (malignant neoplasm of prostate) AND documentation confirms the procedure is for rectal toxicity reduction during radiotherapy; (2) CPT 55874 billed for any other indication (salvage radiotherapy, post-operative settings not meeting criteria, or other uses) must be submitted as experimental/investigational and will require prior authorization or will be denied as non-covered; (3) Providers must document in clinical notes that the procedure is specifically for reducing rectal toxicity during prostate cancer radiotherapy; (4) Update prior authorization workflows to flag CPT 55874 claims without proper C61 diagnosis coding or clinical documentation of rectal toxicity reduction purpose. Front desk and clinical staff should add a reminder to encounter forms to ensure providers document the specific indication. Failure to properly code and document will result in claim denials for medical necessity.