Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Enlarged prostate

Treatment: vascular embolization

The insurer denied coverage for vascular embolization

The denial is upheld

 
According to the medical records, the patient is an adult male patient who is being evaluated for the treatment of Benign prostatic hyperplasia (BPH). The patient presented to the Interventional Radiologist's office for a prostate artery embolization consultation. The patient reported often having sensations of incomplete bladder emptying. The physician discussed treatment options with the patient. The patient was an excellent candidate for prostate artery embolization which is under review.

As per McVary K, et al.[10]: Prostatic arterial embolization (PAE) is an experimental minimally invasive surgical treatment (MIST) for benign prostatic hypertrophy (BPH). Given the heterogeneity in the available literature and safety concerns regarding radiation exposure, postembolization syndrome, vascular access, technical feasibility, and adverse events [3], the American Urological Association (AUA) BPH clinical guidelines state that "PAE for the routine treatment of BPH is not supported by current data, and benefit over risk remains unclear; therefore, PAE is not recommended outside the context of clinical trials."

PAE uses digital subtraction angiography to define the arterial anatomy and selectively embolize the appropriate prostatic arterial supply with beads, gels, or nonspherical polyvinyl alcohol. As a result, the prostate undergoes ischemic necrosis and subsequent volume reduction, which putatively improves the condition.

While all other technologies described above specifically target the critical areas of bladder outlet obstruction (BOO) caused by BPH, PAE impacts the entire prostate without exerting any focused and controlled action on the obstruction. This may explain the higher clinical failure rate compared with more traditional methods (e.g., transurethral resection of the prostate [TURP]) [4-7] and the commonly observed complications such as acute urinary retention in almost 26 percent of cases [8].

Prostatic arteries may be very difficult to identify because of a lack of pathognomonic findings. Nontargeted embolization may lead to ischemic complications of the prostate, bladder, or seminal vesicles. Other short-term complications, including urethral burning sensation, nausea, and vomiting, which have been called the "post-PAE syndrome," are common [9]. Furthermore, radiation and contrast toxicity may lead to additional adverse events.

"Conclusion: Pre-operative and surgical management of BPH requires attention to individual patient characteristics and procedural risk. Clinicians should adhere to recommendations and familiarize themselves with criteria that yields the highest likelihood of surgical success when choosing a particular approach for a particular patient." (Lerner, L. B. et al. 2021).

"Conclusion: PAE could be considered a feasible minimally invasive technique but failed to demonstrate superiority because of the increased risk of persistent symptoms." (Russo, G. I., et al. 2015).

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for vascular embolization is not substantiated.