A wide variety of minimally invasive therapies and surgery are available for enlarged prostate and may include but is not limited to:
Conditions requiring treatment of the prostate gland may include but are not limited to:
Oral pharmacological treatments and hydrogel spacer are not addressed in this policy.
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 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 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:
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:
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:
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:
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:
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 |
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:
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 |
|
|
|
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:
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:
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.