| Highmark Commercial Medical Policy - Pennsylvania |
| Medical Policy: | S-97-018 |
| Topic: | Treatment of the Prostate |
| Section: | Surgery |
| Effective Date: | April 25, 2016 |
| Issue Date: | April 25, 2016 |
| Last Reviewed: | March 2016 |
Conditions related 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. 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. 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. |
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.
| Policy Position Coverage is subject to the specific terms of the member’s benefit plan. |
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:
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:
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:
| Place of Service: Inpatient/Outpatient |
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.
| The policy position applies to all commercial lines of business |
| FEP Guidelines |
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. |
| Denial Statements |
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.
| Links |
04/2016, Urolift for Benign Prostatic Hypertrophy to be Considered Medically Necessary When Coverage Criteria Are Met