The following procedures are considered eligible when used to treat various prostate conditions.

• Cryosurgical ablation of the prostate (code 55873) - eligible when performed as the primary treatment for prostate cancer (185, 189.3, 198.82, 233.4, 236.5)
• Transurethral microwave thermotherapy (TUMT) of the prostate (code 53850)
• Transurethral needle ablation (TUNA) of the prostate (code 53852)
• Laser ablation of the prostate (codes 52647, 52648)
• Transurethral resection of the prostate (TURP) (codes 52601-52640)

The following procedures are not eligible for payment.

Transurethral balloon dilation of the prostate (code 52510) - Transurethral balloon dilation of the prostate (code 52510) is not generally accepted by the medical community as clinically useful in the diagnosis or treatment of benign prostatic hyperplasia. Other treatment modalities including, but not limited to TURP, TUNA, TUMT, cryosurgical ablation, and laser resection of the prostate are currently used to diagnose and/or treat BPH. Therefore, transurethral balloon dilation of the prostate is considered not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service.

Date Last Reviewed: 05/2001

Transurethral cryosurgical removal of the prostate (code 55899) - This service is considerd a procedure of questionable current usefulness (POQCU). Refer to Highmark Medical Policy Bulletin G-21 for additional information.

Date Last Reviewed: 08/1994

For information on prostatic massage (53899), see Medical Policy Bulletin V-31.

For information on transrectal ultrasound of the prostate, see Medical Policy Bulletin X-25.

Description

The prostate is a gland located around the urinary outlet of the bladder in the male body. About the size of a walnut, the prostate is comprised of two side-by-side lobes connected in the front by a narrowed part of the gland and from behind by a middle lobe that lies above and between the ejaculatory ducts. The gland secretes a milky fluid that is discharged by excretory ducts into the prostatic urethra at the time of emission of semen.

Conditions relating to the prostate gland include, but are not limited to:

Benign prostatic hyperplasia (BPH): The prostate has become enlarged, narrowing the urethra, which causes prostatism and is noted by nocturia, hesitancy, slow stream, terminal dribbling and frequency of urination. Surgical removal of the prostate may be required.

Prostatitis: The prostate has become inflamed due to infection or non-infectious inflammation causing pain in the bladder region, frequency of urination and blood in the urine. Surgery is rarely indicated or helpful. Instead, the disease is generally treated with antibiotics and/or anti-inflammatory medication.

Prostatic carcinoma: Carcinoma of the prostate is one of the most common malignancies in men. In its early stages, most men show no physical signs of malignancy. The disease may be identified by a pathologist when prostate tissue is removed for relief of benign prostatic hyperplasia. More advanced cancer is detected by a hard nodule on the prostate felt during a rectal exam. The diagnosis of cancer is usually confirmed by a needle biopsy. The method of treatment depends upon the extent of the malignancy, but generally involves radiation therapy, radical prostatectomy, or hormonal therapy.

There are various procedures available for treatment of the above conditions. They include, but are not limited to:

Cryosurgical ablation of the prostate (code 55873): A probe, which is used to apply a freezing material such as liquid nitrogen, is inserted through an opening in the perineum and guided by transrectal ultrasonography.

Transurethral microwave thermotherapy of the prostate (code 53850): This procedure is a form of thermal therapy that uses microwaves as the heat source to treat symptomatic benign prostatic hyperplasia. A transurethral applicator and a rectal probe are inserted. The specially designed catheter allows the application of microwave heat energy while two cooling channels within the catheter simultaneously circulate coolant water to maintain appropriate temperatures.

Transurethral needle ablation (TUNA) of the prostate (code 53852): This procedure is a form of thermal therapy that uses radiofrequency energy for the treatment of symptomatic benign prostatic hyperplasia. It is also known as transurethral radiofrequency needle ablation (RFNA) of the prostate. This procedure uses a specially designed catheter inserted through the penis to the level of the prostate. Small needles are inserted through the catheter into the prostate to transmit radiofrequency energy which destroys the prostatic tissue that is blocking the flow of urine.

Laser ablation of the prostate (codes 52647, 52648): This procedure is commonly performed to treat patients with benign prostatic hyperplasia. Laser energy is delivered to the prostate in three ways. One is the transurethral ultrasound-guided laser-induced prostatectomy (or TULIP procedure), another is the "free hand" application of laser energy through a lateral firing fiber. A third method is by direct contact of the prostate tissue with a laser probe to ablate or photocoagulate the tissue.

Transurethral balloon dilation of the prostate (code 52510): Transurethral balloon dilation of the prostate is a non-surgical, therapeutic procedure for the treatment of symptomatic benign prostatic hyperplasia (BPH). A flexible balloon catheter is placed in the urethra at the level of the prostate above the external sphincter. The balloon is then inflated for a short period of time to distend the prostatic urethra. This widening process is intended to relieve the symptoms of benign prostatic hyperplasia.

Transurethral cryosurgical removal of the prostate (code 55899): The prostate is frozen and removed through the urethra for relief of benign prostatic hyperplasia.

Transurethral resection (TUR)(codes 52601-52640): This is an operation to relieve bladder neck and urethral obstructionby removing a portion of the prostate glandthrough the penis. This procedure is the most common technique for relief of benign prostatic hyperplasia.

NOTE:

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.

Cryosurgery of the prostate continues to be considered investigational for salvage therapy for local failures after radical prostatectomy, external beam irradiation, and brachytherapy.

PRN References

10/1993, Treatment of the prostate
08/1994, Cryosurgery of the prostate
08/1996, Transurethral microwave thermotherapy
02/1997, Laser resection of the prostate
06/1998, Transurethral needle ablation of the prostate considered investigational
10/1998, Transurethral microwave thermotherapy of the prostate
10/1999, Transurethral radiofrequency needle ablation of the prostate now covered
02/2000, Cryosurgical ablation of the prostate now covered
10/2001, Coverage change for transurethral balloon dilation of the prostate

Preliminary Outcomes Following Cryosurgical Ablation of the Prostate in Patients with Clinically Localized Prostate Cancer, The Journal of Urology, Vol. 159, 2/98

Outcome and Safety of Transrectal US-Guided Percutaneous Cryotherapy for Localized Prostate Cancer, Journal of Vascular Interventional Radiology, Vol. 10, 2/99

Prostatism: Benign Prostatic Hyperplasia, Urologic Clinics of North America, Vol. 23, No. 1, 02/1996