Any ONE of the following procedures is considered eligible when used to treat prostate conditions.

• Cryosurgical ablation of the prostate (55873) as treatment of clinically localized (organ-confined) prostate cancer when performed
  • As initial treatment; or
  • As salvage treatment of disease that recurs following radiation therapy; or
• Water-induced thermotherapy (WIT), also called thermourethral hot-water therapy of the prostate (code 53850); or
• Transurethral needle ablation (TUNA) of the prostate (code 53852); or
• Laser ablation of the prostate (codes 52647, 52648, 52649); or
• Transurethral resection of the prostate (TURP)(codes 52601-52640); or
• Open/laparoscopic prostatectomy; or
• Transurethral microwave thermotherapy (TUMT).

Services that do not meet the criteria of this policy will not be considered medically necessary. A Pennsylvania participating, preferred or 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. Out of Network/Non-participating providers and providers located outside of Pennsylvania may be able to bill members if the service is denied.

The following procedures are considered experimental/investigational:

• Subtotal prostate cryoablation in the treatment of prostate cancer (55873); and
• High-intensity focused ultrasound (HIFU) ablation for the treatment for BPH (55899); and
• Placement of temporary prostatic stents for the treatment for BPH (53855); and
• Prostatic arterial embolization(37243)

See Medical Policy Bulletin Z-24, Miscellaneous Services.

A participating, preferred, or network provider can bill the member for the denied service. 

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

Place of Service:

Cryosurgical ablation of the prostate: Inpatient

Laser ablation of the prostate: Inpatient/Outpatient

The use of laser prostatectomy is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances including, but not limited to, post op complications, or increased risk due to co-morbid conditions that increase the patient's surgical risk.

Transurethral Microwave Thermotherapy: Outpatient

The use of transurethral microwave thermotherapy is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances including, but not limited to, post op complications, or increased risk due to co-morbid conditions that increase the patient's surgical risk.

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 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, 52649): 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, photocoagulate, vaporize, or enucleate the tissue.

Transurethral resection (TUR)(codes 52601-52640): This is an operation to relieve bladder neck and urethral obstruction by removing a portion of the prostate gland through 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.

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program.

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
12/2012, Place of service designation included on additional medical policies
10/2013, Criteria added for treatment of the prostate
10/2014, Prostatic arterial embolization considered experimental/investigational

Facility Bulletin

02/2014, ADDITIONAL COMMERCIAL MEDICAL POLICIES WILL APPLY TO  SELECT OUTPATIENT FACILITY SERVICES ON MARCH 3, 2014

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

BCBSA Medical Policy 7.01.52. Tranurethral Microwave Thermotherapy. 2011.

BCBSA Medical Policy 7.01.79. Cryoablation of Prostate Cancer. 2012.

Wolff JM, Mason M. Drivers for change in the management of prostate cancer - guidelines and new treatment techniques. BJU Int. 2012;109 Suppl 6:33-41.

Qi J, Yu YJ, Huang T, et al. Comparation of the predictive value between ultrasonography and urodynamics for the efficacy of transurethral resection of prostate in benign prostatic hyperplasia patients. Chin Med J (Engl). 2012;125(9):1536-41.

Wolff JM, Mason M. Drivers for change in the management of prostate cancer - guidelines and new treatment techniques. BJU Int. 2012;109 Suppl 6:33-41.

InterQual® Level of Care 2012. Acute Care Adult. McKesson Health Solutions, Inc.

BCBSA Medical Policy 7.01.52. Tranurethral Microwave Thermotherapy. August 2012.

BCBSA Medical Policy 7.01.79. Cryoablation of Prostate Cancer. 2012, May 2013.

Shrivastava A, Gupta V. Various treatment options for benign prostatic hyperplasia: A current update. Journal of Mid-Life Health. 2012 Jan-Jun;3(1): 10-19.

Hale Z, Miyake M, Palacios D A, et al. Focal cryosurgical ablation of the prostate: a single institute’s perspective. BioCentral Urology. 2013;13:2.

Thiruchelvam N. Surgical therapy for benign prostatic hypertrophy/bladder outflow obstruction. Indian J Urol. 2014; 30(2): 202–207.

Carnevale FC, Antunes AA, Motta-Leal-Filho JMD, et al. Review of Current Outcomes of Prostate Artery Embolization to Treat Patients with Lower Urinary Tract Symptoms Due to Benign Prostatic Hyperplasia. UroToday International Journal. 2012;5.

McVary KT, Roehrborn CG, Avins AL, et al. American Urological Association Guideline: Management of Benign Prostatic Hyperplasia (BPH). 2014.