Treatment of the Prostate

Policy ID: S-97-030

Section: Surgery

Effective Date: July 01, 2018

Revised Date: December 21, 2020

Revision Effective Date: January 01, 2021

Last Reviewed: January 19, 2021

Description

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.

Criteria

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) (for example Greenlight laser); or
- Transurethral electrovaporization of the prostate (TUEVP, TUVAP or TUEVAP); 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 volume is less than 80 grams; and
- Water vapor thermal therapy (e.g., Rezum) when prostate volume is less than 80 grams; or
- Transurethral incision of the prostate (TUIP); and
The individual has a diagnosis of lower urinary tract symptoms (LUTS) secondary to 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 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).

The surgical and minimally invasive treatment of urinary outlet obstruction when using one of the procedures above may be considered medically necessary when the individual has a diagnosis or history of prostate cancer and meets ONE 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 than 1.0 ng/mL.

A radical prostatectomy may be considered medically necessary for individuals with a diagnosis of localized prostate cancer.

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

Procedure Codes

52441	52442	52450	52601	52630	52640	52647
52648	52649	53850	53852	53854	55801	55810
55812	55815	55821	55831	55840	55842	55845
55866

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.

Procedure Codes

55873

55880

The use of any focal therapy modality treatment for individuals with localized prostate cancer is considered experimental/investigational (E/I) and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature. Examples of focal Modalities include, but are not limited to, the following:

Laser ablation; or
High-intensity focused ultrasound (HIFU); or
Cryoablation; or
Radiofrequency ablation; or
Photodynamic therapy.

Procedure Codes

55899

The following procedures are considered experimental/investigational for the treatment of BPH and therefore noncovered. 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)

Procedure Codes

37243

53855

53880

53899

55873

55880

55899

Outpatient HCPCS (C Codes)

C9739

C9740

C9747

C9769

Diagnosis Codes

Covered diagnosis codes for procedure codes: 52441, 52442, 52450, 52601, 52630, 52640, 52647, 52648, 52649, 53850, 53852, 53854, 55801, 55810, 55812, 55815, 55821, 55831, 55840, 55842, 55845, 55866.

D29.1	D40.0	D49.59	N32.0	N32.89	N32.9	N39.41
N39.42	N39.43	N39.44	N39.45	N39.46	N40.0	N40.1
N40.2	N40.3	N41.0	N41.1	N41.2	N41.3	N41.4
N41.8	N41.9	N42.83	N42.89	N42.9

Covered diagnosis codes for procedure codes: 52441, 52442, 52601, 52630, 52640, 52647, 52648, 52649, 53850, 53852, 55873, 55880, 55866

C61

C79.82

D07.5

Z85.46

Covered diagnosis codes for procedure codes: 55810, 55812, 55815, 55840, 55842, 55845 and 55866

C61

C79.82

D07.5

D40.0

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 9-21-2020 Coding update: Added C9769 to Outpatient HCPCS (C Codes)

Internal Medical Policy Committee 1-19-2021 Coding update: Added 55880

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving and the Company reserves the right to review and update medical policy periodically.

Policy ID: S-97-030

Section: Surgery

Effective Date: November 01, 2019

Revised Date: September 29, 2020

Revision Effective Date: November 02, 2020

Last Reviewed: September 21, 2020

Archived Date: December 31, 2020

Description

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.

Criteria

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) (for example Greenlight laser); or
- Transurethral electrovaporization of the prostate (TUEVP, TUVAP or TUEVAP); 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 volume is less than 80 grams; and
- Water vapor thermal therapy (e.g., Rezum) when prostate volume is less than 80 grams; or
- Transurethral incision of the prostate (TUIP); and
The individual has a diagnosis of lower urinary tract symptoms (LUTS) secondary to 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 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).

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 than 1.0 ng/mL.

A radical prostatectomy may be considered medically necessary for individuals with a diagnosis of localized prostate cancer.

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

Procedure Codes

52441	52442	52450	52601	52630	52640	52647
52648	52649	53850	53852	53854	55801	55810
55812	55815	55821	55831	55840	55842	55845
55866

Whole gland 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 is considered not medically necessary.

Procedure Codes

55873

Laser ablation; or
High-intensity focused ultrasound (HIFU); or
Cryoablation; or
Radiofrequency ablation; or
Photodynamic therapy.

Procedure Codes

55899

The following procedures/treatments for BPH are considered E/I and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature:

HIFU ablation for the treatment for BPH;
Placement of temporary prostatic stents for the treatment for BPH;
Prostatic arterial embolization;
Focal laser ablation (Visualase).

Subtotal prostate cryoablation for the treatment of prostate cancer is considered E/I and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

37243

53855

53899

55873

55899

Outpatient HCPCS (C Codes)

C9739

C9740

C9747

C9769

Diagnosis Codes

Covered diagnosis codes for procedure codes: 52441, 52442, 52450, 52601, 52630, 52640, 52647, 52648, 52649, 53850, 53852, 53854, 55801, 55810, 55812, 55815, 55821, 55831, 55840, 55842, 55845, 55866

D29.1	D40.0	D49.59	N32.0	N32.89	N32.9	N39.41
N39.42	N39.43	N39.44	N39.45	N39.46	N40.0	N40.1
N40.2	N40.3	N41.0	N41.1	N41.2	N41.3	N41.4
N41.8	N41.9	N42.83	N42.89	N42.9

Covered diagnosis codes for procedure codes: 52441, 52442, 52601, 52630, 52640, 52647, 52648, 52649, 53850, 53852, 55873, 55866

C61

C79.82

D07.5

Z85.46

Covered diagnosis codes for procedure codes: 55810, 55812, 55815, 55840, 55842, 55845 and 55866

C61

C79.82

D07.5

D40.0

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 9-21-2020 Coding update: Added C9769 to Outpatient HCPCS (C Codes)

Links

References (PDF)

Disclaimer

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