Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Physician 1:  The patient is a 60-year-old male with symptoms of prostatism including urinary hesitancy, weak stream, and nocturia. On digital rectal examination he was found to have a significantly enlarged prostate gland. His PSA level was last reported in July 2005 to be normal. The patient has not sufficiently responded to adequate medical, non-operative treatment, which has included three different alpha adrenergic blockers (Cardura, Flomax, and Uroxatral) and a 5-alpha reductase inhibitor (Proscar). He therefore wishes to have surgical treatment of his benign prostatic hypertrophy. His choice of surgical procedure is Holmium laser resection/enucleation of the prostate. The Health Plan has denied coverage for the requested procedure on the basis that it is experimental and investigational with safety and efficacy not well established.This patient with symptomatic benign prostatic hypertrophy has not responded adequately to treatment with oral medications and has decided to have surgery to relieve his problem. The surgical procedure he and his treating urologist have chosen is that of transurethral Holmium laser vaporization of the prostate. This is a well-recognized and acceptable surgical treatment for benign enlargement of the prostate, with results at least comparable to other surgical treatments. In fact, a recent article by Rigatti and associates in Urology in June 2006 reported that objective post-operative results were determined to be at least as good as those of traditional transurethral prostatic resection. The authors concluded, Considering the comparable urodynamic findings between the two groups, HoLEP seems a very attractive alternative to standard TURP, owing to the lower incidence of perioperative morbidity, reduced blood loss, quicker catheter removal, and shorter hospital stay.Allowing for some variation in results by different studies, the Holmium laser procedure requested by the patient is an acceptable treatment whose safety and efficacy in appropriately selected patients has been established. Therefore, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2:  This patient is a 60-year-old male with progressive lower urinary tract symptoms that have not been relieved by X-blocker or Proscar. He has discussed his treatment options with his provider and wishes to undergo Holmium laser vaporization of the prostate. The Health Plan had denied coverage for the requested procedure citing a lack of proven efficacy.Holmium laser vaporization of the prostate is not experimental. Multiple obliterative procedures are currently performed and have been approved by the Food and Drug Administration. However, based upon the information provided it has not been established that surgical intervention is necessary in the case of this patient. A more complete workup of the patients BPH should be performed including cystoscopy findings, urine flow analysis and a voiding diary before the requested procedure is pursued. For the reasons set forth above, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3:  The patient is a 60-year-old male with a history of bladder control problems. The patient has failed to respond to multiple medications including Cardura, Flomax, Uroxatral and Proscar. The patient and his provider have requested authorization for Holmium laser vaporization of the prostate. The Health Plan indicates the requested procedure is investigational and therefore has denied the patients request for coverage.Holmium laser vaporization of the prostate is neither experimental nor investigational. It is the most common method of relieving bladder control symptoms due to an enlarged prostate. The procedure is safe, reliable and effective and has been used to treat thousands of patients. It is the treatment of choice in this clinical setting and should be authorized. Accordingly, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.