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.

The patient is an adult male with a history of benign prostatic hyperplasia (BPH) manifested by nocturia, increased frequency, urgency, and straining. He has no contraindication to standard medical and surgical techniques to treat this condition. The provider wishes to perform prostatic artery embolization (PAE), which the plan is denying as an experimental therapy.

There is a lack of peer-reviewed randomized literature supporting an improved outcome with PAE compared to standard treatments.

The 2020 updated American Urological Association (AUA) evidence-based guideline on the "Surgical Management of Benign Prostatic Hyperplasia/Lower Urinary Tract Symptoms" (LUTS) stated that: Artery Embolization (PAE) for the treatment of LUTS secondary to BPH is not supported by current data and trial designs, and benefit over risk remains unclear; therefore, PAE is not recommended outside the context of clinical trials.

Abt D, Hechelhammer L, Mullhaupt G, Markart S, Gusewell S, Kessler TM, et al. (2018), "The improvement in lower urinary tract symptoms secondary to benign prostatic hyperplasia seen 12 weeks after PAE is close to that after TURP (Transurethral resection of the prostate). PAE is associated with fewer complications than TURP but has disadvantages regarding functional outcomes, which should be considered when selecting patients. Further comparative study findings, including longer follow-up, should be evaluated before PAE can be considered as a routine treatment."

The use of PAE for this indication is an approved procedure by the Society of Interventional Radiology and the Food and Drug Administration (FDA).

According to the Society of Interventional Radiology Position Statement, the patient would be a good candidate for PAE, however other medical societies claim an inferior result with PAE compared to other standard treatments. Based on the records, the patient has no contraindication to standard medical therapies.

There is a lack of peer-reviewed literature that supports PAE being the best available treatment compared with standard techniques that have had longer follow-ups and are supported by a larger database.

There is an insufficient long-term follow-up to opine whether the adverse risks of PAE are not increased over standard treatments. 

In a guideline on the management of non-neurogenic male LUTS, the European Association of Urology (EAU) offers a weak recommendation for prostatic arterial embolization in individuals who would like a minimally invasive treatment option and have been made aware that outcomes are less optimal than transurethral resection of the prostate (TURP). Additionally, the EAU points out that this treatment option remains under investigation and should only be offered in facilities where the urologist is working collaboratively with a trained interventional radiologist (Gravas et al., 2021).

There are no peer-reviewed randomized studies that suggest an improved outcome with prostatic artery embolization compared with other standard medical techniques for managing this condition. Based on the records the patient has no contraindication to standard medical therapies or clinical reasons to avoid them. 

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.