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

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

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

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

Outpatient HCPCS (C Codes)

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

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

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