This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

The surgical and minimally invasive treatment of urinary outlet obstruction due to benign prostatic hyperplasia (BPH) may be considered medically necessary when ALL of the following criteria are met:

• ONE of the following procedures is utilized:
  • Transurethral Resection of the Prostate (TURP); or
  • Holmium laser ablation of the prostate [HoLAP]; or
  • Holmium laser enucleation of the prostate [HoLEP]; or
  • Holmium laser resection of the prostate [HoLRP]; or
  • Photoselective laser vaporization (PVP); or
  • Transurethral electrovaporization of the prostate (TUEVP, TUVAP or TUEVAP); or
  • Transurethral needle ablation  (TUNA), also called transurethral radiofrequency needle ablation (RFNA); or
  • Transurethral ultrasound-guided laser-induced prostatectomy (TULIP); or
  • Transurethral microwave thermotherapy (TUMT); or
  • Water-induced thermotherapy (WIT), also called thermourethral hot-water therapy; or
  • Open/laparoscopic prostatectomy; or 
  • Prostatic urethral lift (UroLift);
    • When prostate size is no greater than 80 grams; and
    • There is no median lobe enlargement present; and
    • The patient has normal renal function; and
• The individual has a diagnosis of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) (e.g., increased urinary frequency, urgency, incontinence, or straining; nocturia; decreased and intermittent force of the stream; hematuria; and the sensation of incomplete bladder emptying) that interfere with activities of daily living; and
• The individual has a prostate-specific antigen (PSA) blood test that meets BOTH of the following criteria:
  • Given within 12 months of the procedure; and
  • Resulted in a value of 2.5 ng/mL or less for individuals who are up to and including 60 years of age and 4.0 ng/mL or less for individuals who are over 60 years of age; and
• The individual has a peak urine flow rate (Qmax) less than 15 cc/sec on a voided volume that is greater than 125 cc; and
• The individual has failed a trial of satisfactory voiding with medication (alpha blocker and/or alpha-reductase inhibitor) or intolerance to medication (alpha blocker and/or 5-alpha-reductase inhibitor); and
• The individual has a diagnosis or history of prostate cancer and meets either of the following criteria:
  • The individual is not a candidate for surgical resection of the prostate but will be treated by radiation therapy and has symptoms that are so severe that immediate relief is required; or
  • The individual is clinically in remission as evidenced by a PSA less than1.0 ng/mL.

The use of any of the procedures listed above for any other indication will be considered not medically necessary.

Cryosurgical ablation of the prostate gland as treatment of clinically localized (organ confined) prostate cancer may be considered medically necessary when performed:

• As initial treatment; or 
• As salvage treatment of disease that recurs following radiation therapy.

The use of cryosurgical ablation of the prostate gland for any other indication will be considered not medically necessary.

The following procedures are considered experimental/investigational for the treatment of BPH and therefore non-covered. Scientific evidence does not support the use any of the procedures listed below:

• Subtotal prostate cryoablation in the treatment of prostate cancer;
• High-intensity focused ultrasound (HIFU) ablation for the treatment for BPH;
• Placement of temporary prostatic stents for the treatment for BPH;
• Prostatic arterial embolization;
• Focal laser ablation (Visualase)

Experimental/Investigational (E/I) services are not covered regardless of place of service.

Cryosurgical ablation of the prostate is considered an inpatient procedure.

Treatment of the prostate is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

• Link to Provider Resource Center for the Medical Policy Update

04/2016, Urolift for Benign Prostatic Hypertrophy to be Considered Medically Necessary When Coverage Criteria Are Met

• Link to Diagnosis Codes

• Link to References