Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Benign prostatic hyperplasia (BPH).
Treatment: Prostate artery embolization/ambulatory surgery.
The insurer denied coverage for prostate artery embolization/ambulatory surgery.
The denial is upheld.

This case involves a male diagnosed with benign prostatic hyperplasia. The patient is seeking coverage for prostate artery embolization/ambulatory surgery. In a determination letter, it was stated that the request for prostate artery embolization/ambulatory surgery was denied. The request was denied as the service was considered experimental/investigational. 

Xiang et. al. (2021), found that prostate artery embolization (PAE) for benign prostatic hyperplasia was found to be non-inferior to transurethral resection of the prostate (TURP) regarding improving patient-reported outcomes, the most functional parameters undergo more changes after transurethral resection of the prostate then after prostate artery embolization. Moreover, prostate artery embolization could significantly continue to relieve symptoms for 24 months without causing serious complications. It was found to be as effective as transurethral resection of the prostate with fewer complications and shorter hospitalization times. However, it was found to be inferior and improvement of most functional outcomes. Knight et. al. (2021) notes that subjective symptom improvement was equivalent between TURP and PAE. While TURP demonstrated larger improvements for some objective parameters, PAE was associated with fewer adverse events (AEs) and shorter hospitalization times. According to the American Urological Association, PAE for the routine treatment of LUTS (lower urinary tract symptoms) /BPH is not supported by current data, and the benefit over risks remains unclear. Therefore, PAE is not recommended outside the context of clinical trials.

In this case, the patient was diagnosed with benign prostatic hyperplasia. The provider noted that the patient had been diagnosed with lower urinary tract symptoms, nocturia 2 times a night, increased frequency, urgency, weak stream, and straining. It was noted that the patient had complicated lower urinary tract and symptoms with an international prostate symptom score of 23 (severe) and a quality of living rating of 5. The patient had been seen by vascular and interventional radiology who agreed that prostatic artery embolization was the best treatment option for the management of the patient's benign prostatic hyperplasia.

There is some scientific evidence in the literature to support a result of improvement in health outcomes with the requested intervention. However, the literature also notes that the treatment was found to be inferior to the gold standard treatment of TURP regarding functional outcomes.  As noted by the American Urological Association, the PAE procedure does not have approval from the appropriate regulatory bodies outside of an experimental setting. The risk over benefits remains unclear. The provided documentation was also limited to the patient's physical condition and prior treatment attempts. Thus, there is no compelling evidence that this treatment would be more appropriate for this patient compared to standard treatments, that the patient is a good candidate, or that it is the best available treatment for this patient at this time. As such, the denial of coverage for prostate artery embolization/ambulatory surgery was appropriate and is upheld.

The requested procedure is not likely to be more beneficial than any of the standard treatment/procedures for this patient.

The insurer's denial of prostate artery embolization/ambulatory surgery is upheld.