UTMB
Dr. Walser Letterhead
Date
Re: Mr. Patient Name, Member Number and Date of Birth
Request for Laster Interstitial Tumor Therapy (LITT) for the Prostate
Attention: Predetermination Department
The purpose of this letter is to request a medical predetermination review to perform Laser Interstitial
Tumor Therapy (LITT) for the Prostate on Mr. Patient Smith, who was recently diagnosed with localized
cancer of the prostate.
This procedure will be performed with MRI guidance which allows accurate placement of instruments
without radiation exposure. The laser fiber, when activated in the prostate, creates a very precise zone
of tumor necrosis which is monitored real-time by special temperature sensitive MRI-sequences. The
highly controlled and targeted tumor destruction is much less invasive than prostatectomy. Surgery
results in a significant rate of life-changing complications such as incontinence and impotence, which
lead to further costs and inconvenience to the patient. LITT causes these major complications in less
than 5% of cases. Furthermore, LITT is less expensive than other standard treatments such as
chemotherapy and radiation. While radiation therapy protocols require up to 40 weeks of treatment
and surgery requires several days in the hospital and 4-6 weeks of recovery, LITT can be done in one day
with no admission or only an overnight stay. More specific information about the procedure is attached.
This new thermal ablative technique is cleared by the FDA for human use. The FDA letter of approval of
the device used for the procedure is also included. As this is a new procedure, a specific code has not
yet been identified. We are using the unlisted procedure code of 55899.
Mr. Smith is a good candidate for this technique as he presents with a focal prostate cancer confined to
the gland and with biopsy proof of favorable histology. His medical records documenting his current
diagnosis are attached. The following list summarizes the enclosed information. Thank you in advance
for your consideration. If you have specific questions about this procedure, please contact me directly
at 409-747-0100.
Best regards,
Eric Walser, MD
Professor and Chairman of Radiology
Director of Interventional Radiology
UTMB—Galveston Texas
Contents of Enclosure:
1) Procedure Request Form
2) Information on Laser Interstitial Tumor Therapy for the Prostate
3) Device Approval Letter from the FDA
4)
5)
6)
7)
8)
Pathology Report
Imaging studies
Dynamic prostate MRI report
Biopsy Report
Etc.