Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Benign prostatic hyperplasia (BPH). 
Treatment: Prostate artery embolization (PAE) (a procedure to treat enlarged prostate gland). 
The insurer denied coverage for prostate artery embolization (PAE) (a procedure to treat enlarged prostate gland). 
The denial is upheld. 

This case pertains to a patient with a review of a request for prostate artery embolization (PAE). 

The patient presented with urinary frequency. The patient has a history of benign prostate hypertrophy (BPH), erectile dysfunction, and Peyronie's. The patient currently takes Tamsulosin. Review found frequency without hematuria. Exam found enlarged prostate without discrete nodule-30 gram. The plan was to stop tamsulosin and start alfuzosin. 

The patient presented for follow up on their benign prostate hypertrophy. The patient currently takes alfuzosin. The patient reports good force of stream, but only small volume voided. The patient voids every 2 hours during the day and is up 3 times at night. The patient's bladder scan showed a 219 milliliter (ml) residual. Urinalysis (UA) results were normal. Cystoscopy showed pendulous and bulbar urethra was normal without strictures or mucosal abnormalities. Large bilobar prostatic hyperplasia with median lobe, and high bladder neck-prostate length of 4 centimeters (cm) were noted. Assessment is BPH with obstructive and irritative symptoms. The provider documented discontinuation of alfuzosin as the patient had increased complaints. The provider noted the patient is a good candidate for a transurethral resection of the prostate (TURP). 

Several weeks later, the patient presented via telephone to discuss possible prostate artery embolization (PAE). The record indicates the patient is maintained on alfuzosin. 

The provider sent an appeal letter. The provider noted that prostate artery embolization was selected as the preferred treatment option given it is minimally invasive and has minimal side effects. It has been shown to be at least as effective as transurethral resection of the prostate and existing literature supports it as safe and effective. It is a valuable treatment option for patients who want to avoid invasive surgery. 

The plan language notes that based upon their criteria and assessment of the peer-reviewed literature, prostate artery embolization has not been medically proven to be effective for patients as a treatment for BPH. 

Literature found that "many studies have shown clinical results that are comparable to the current surgical gold standard, transurethral resection of the prostate. The use of prostate artery embolization offers similar results with fewer complications and fewer side effects, while eliminating the need for general anesthesia or hospitalization. While long-term evidence demonstrating the durability of PAE is still forthcoming, the procedure has been demonstrated to be safe according to multiple meta-analyses. The American Urological Association noted PAE may be offered for the treatment of lower urinary tract symptoms (LUTS)/BPH. PAE should be performed by clinicians trained in this interventional radiology procedure following a discussion of the potential risks and benefits. The Panel recommends that these procedures are only performed by physicians specifically trained in this technique. The Panel recommends continued investigation of PAE through trials involve multi-disciplinary teams of urologists and radiologists focused on further defining specific indications, including but not limited to gross hematuria recalcitrant to other therapies" (1). 

In summary, the denial of a prostate artery embolization (a procedure to treat enlarged prostate gland) and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.