HIGHMARK COMMERCIAL MEDICAL POLICY - DELAWARE

 
 
Medical Policy:
S-97-022
Topic:
Treatment of the Prostate
Section:
Surgery
Effective Date:
March 29, 2021
Issued Date:
March 29, 2021
Last Revision Date:
March 2021
Annual Review:
March 2021
 
 

A wide variety of minimally invasive therapies and surgery are available for enlarged prostate and may include but is not limited to:

  • Cryoablation of the prostate; or
  • Holmium laser:
    • Ablation of the prostate [HoLAP]; or
    • Enucleation of the prostate [HoLEP]; or
    • Resection of the prostate [HoLRP]; or
  • Photoselective laser vaporization (PVP); or
  • Prostatic urethral lift (PUL); or
  • Radical prostatectomy; or
  • Simple prostatectomy; or
  • Transurethral electrovaporization of the prostate (TUEVP, TUVAP or TUEVAP); or 
  • Transurethral microwave thermotherapy (TUMT); or 
  • Transurethral resection of the prostate (TURP); or
  • Transurethral ultrasound-guided laser-induced prostatectomy (TULIP); or
  • Water-induced thermotherapy (WIT), also called thermourethral hot-water therapy; or
  • Water vapor thermal therapy (e.g., Rezum) when prostate volume is less than 80 grams.

Conditions requiring treatment of the prostate gland may include but are not limited to:

  • Benign prostatic hyperplasia (BPH); or
  • Prostate cancer; or
  • Prostatitis.

Oral pharmacological treatments and hydrogel spacer are not addressed in this policy.

Policy Position

The surgical and minimally invasive treatment (e.g., HoLAP, HoLEP, HOLRP, PVP, TUEVP, TUVAP, TUEVAP, TUMT, TURP, TULIP, WIT) of urinary outlet obstruction due to BPH may be considered medically necessary when ALL the following criteria are met:

  • The individual has a diagnosis of lower urinary tract symptoms (LUTS) secondary to BPH 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 (e.g., HoLAP, HoLEP, HOLRP, PVP, TUEVP, TUVAP, TUEVAP, TUMT, TURP, TULIP, WIT) of urinary outlet obstruction due to prostate cancer may be considered medically necessary when ONE the following criteria are met:

  • The individual with a diagnosis or history of prostate cancer and 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 with a diagnosis or history of prostate cancer and is clinically in remission as evidenced by a prostate specific antigen (PSA) less than1.0 ng/mL.

The use of any treatments/procedures  not meeting the criteria as indicated in this policy is considered not medically necessary.

52441

52442

52450

52601

52630

52640

52647

52648

52649

53850

53852

53854

55821

55831

55866

 

 

 

 

 

 


Prostatectomy

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

A simple or radical prostatectomy not meeting the criteria as indicated in this policy is considered not medically necessary

55801

55810

55812

55815

55840

55842

55845


Prostatic Urethral Lift (PUL)

PUL in individuals 45 years of age or older with moderate-to-severe lower urinary tract obstruction due to BPH may be considered medically necessary when ALL the following criteria are met:

  • Persistent or progressive lower urinary tract symptoms despite medical therapy (α1-adrenergic antagonists maximally titrated, 5α-reductase inhibitors, or combination medication therapy maximally titrated) over a trial period of no less than 6 months, or is unable to tolerate medical therapy; and,
  • Prostate gland volume is less than or equal to100 mL; and,
  • Prostate anatomy demonstrates normal bladder neck without an obstructive or protruding median lobe; and,
  • Individual does not have urinary retention, urinary tract infection, or recent prostatitis (within past year); and,
  • Individual has had appropriate testing to exclude diagnosis of prostate cancer; and,
  • Individual does not have a known allergy to nickel, titanium or stainless steel.

PUL not meeting the criteria indicated in this policy is considered not medically necessary.

52441

52442

 

 

 

 

 


Cryoablation

Whole gland cryoablation 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 radiotherapy.

Whole gland cryosurgical ablation of the prostate gland not meeting the criteria as indicated in this policy is considered not medically necessary.

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

55873

55899

 

 

 

 

 


High-Intensity Focused Ultrasound (HIFU)

Whole gland HIFU may be considered medically necessary as a local treatment for recurrent prostate cancer following radiation therapy when individual meets ALL the following criteria:

  • Original clinical stage (Please see staging tables below):
    •  T1 – T2; and
    •  NX or NO; and
  • Life expectancy of greater than 10 years; and
  • PSA of less than 10 ng/mL; and
  • Positive post-RT transrectal (TRUS) biopsy; and
  • No evidence of metastatic disease.

HIFU not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

55880

55899

 

 

 

 

 


The use of ANY focal therapy modality, including but not limited to the following procedures, for individuals with localized prostate cancer is considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature: 

  • Radiofrequency ablation; or
  • Photodynamic therapy.

55899

 

 

 

 

 

 


The following procedures/treatments for BPH, including but not limited to the following procedures, are considered experimental/investigational 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; or
  • Placement of temporary prostatic stents for the treatment for BPH; or
  • Prostatic arterial embolization;or
  • Focal laser ablation (Visualase).

37243

53855

53899

55873

55880

55899

 


C9739

C9740

C9769

 

 

 

 


Tumor (T) Staging

T1

The tumor is too small to be seen on scans or felt during examination of the prostate (it has been discovered by needle biopsy).

T2

The tumor is completely inside the prostate gland.

T3

The tumor has broken through the capsule of the prostate gland.

T4

The tumor has spread into other body organs.

 

Lymph Node (N) Staging

NO

No cancer cells found in any lymph nodes

N1

One positive lymph node smaller than 2 cm across.

N2

More than 1 positive lymph node; or one that is between 2cm and 5 cm across.

N3

Any positive lymph node that is bigger than 5 cm across.

NX

Lymph nodes cannot be assessed
Professional Statements and Societal Positions Guidelines

National Comprehensive Cancer Network – 2020

The National Comprehensive Cancer Network guidelines (v.3.2020) for prostate cancer indicate cryosurgery and high-intensity focused ultrasound are options for radiotherapy recurrence in patients who have no evidence of metastatic disease.

American Urological Association – 2020

In 2018, the American Urological Association published guidelines on the surgical management of LUTS attributed to BPH; the 2018 guidelines were amended in 2019 and 2020. The guidelines made the following recommendations and statements:

  • Conditional recommendations regarding prostatic urethral lift (PUL):
    • "PUL may be offered as an option for patients with LUTS [lower urinary tract symptoms] attributed to BPH [benign prostatic hyperplasia] provided prostate volume <80g and verified absence of an obstructive middle lobe "
    • "PUL may be offered to eligible patients concerned with erectile and ejaculatory function for the treatment of LUTS attributed to BPH." 
    • "Clinicians should inform patients of the possibility of treatment failure and the need for additional or secondary treatments when considering surgical and minimally-invasive treatments for LUTS secondary to BPH."
  • Conditional recommendations regarding water vapor thermal therapy:
    • Water vapor thermal therapy may be offered to patients with LUTS attributed to BPH provided prostate volume <80g.
    •  Water vapor thermal therapy may be offered to eligible patients who desire preservation of erectile and ejaculatory function.


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, and 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, 55866, 55873, and 55880

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

 

 

 


Place of Service: Inpatient/Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

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



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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 or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract, and subject to the applicable laws of your state.


Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as: 
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as: 
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact the Civil Rights Coordinator. 

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. 

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: 

U.S. Department of Health and Human Services 
200 Independence Avenue, SW 
Room 509F, HHH Building 
Washington, D.C. 20201 
1-800-368-1019, 800-537-7697 (TDD) 

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. 

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. 




Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.