HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
S-97-030
Topic:
Treatment of the Prostate
Section:
Surgery
Effective Date:
October 1, 2020
Issued Date:
October 1, 2020
Last Revision Date:
September 2020
Annual Review:
August 2019
 
 

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.
Policy Position

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 gramsor
    • 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 than1.0 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.

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.

55873

 

 

 

 

 

 




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.

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.

 

37243

53855

53899

55873

55899

 

 



C9739

C9740

C9747

C9769

 

 

 




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

 

 

 



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.