Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Benign Prostatic Hypertrophy and Sequalae.
Treatment:  Prostate Artery Embolization.

The insurer denied the request for prostate artery embolization.  The health plan's determination is overturned.

The patient is a male who presents with a history of prostate issues. His pertinent past medical records note hyperlipidemia and hypertension. He has benign prostatic hypertrophy and sequalae, causing lower urinary tract symptoms (LUTS). This includes dribbling, frequency, nocturia and occasional urine leakage related to urgency. His symptoms are worsening and are refractory to medical management. His International Prostate Symptom Score (IPSS) is listed as 24 or 28; both are in the severe category. He has had no procedure performed. The patient presented with poor quality of life (QOL) as well. He strains to complete voiding.

The pelvic magnetic resonance imaging (MRI) performed with a prostate size at 38 grams (g). The pelvic ultrasound images note a 65 gram prostate, and a post void residual of 171 milliliters (mL). His symptoms are refractory to medical treatment including Tamsulosin then Silodosin and herbal remedies.

The patient's past surgery history was reviewed and there are no known contraindications to anesthesia or surgery. The patient's medications were noted. Laboratory studies were ordered and he was evaluated by a urologist. The current treatment plan is for a prostate artery embolization (PAE) procedure.

The health plan in its determination of medical necessity, did not act reasonably nor with sound medical judgment and not in the best interest of the patient. 

The requested health service/treatment of PAE is medically necessary for this patient. He has a history of significant symptomatic benign prostatic hypertrophy with symptoms/LUTS. The requested PAE treatment is medically necessary to treat this patient's diagnosis and for his ongoing medical care and is a reasonable choice. Any other potential treatment options are mainly provided by urologists. He is concerned about side effects of urethral based procedures and types of surgeries.

The procedure is clinically proven and medically necessary to treat the patient's clinical condition based on high quality evidence and is therefore not considered experimental/investigational/unproven (EIU), and PAE should not occur only as part of a clinical or research trial. It is considered clinically proven, safe and effective.

There are many potential prostate treatment options, mainly provided by urologists. The American Urological Association (AUA) is a resource for the support of alternate surgical procedures, as well as traditional prostate surgery, they are contradictory and biased as they are then advocating against a direct medical competitor, an interventional radiologist's opinion.

This patient has a significant medical issue related to symptomatic prostate enlargement and meets criteria for treatment. This makes PAE medically necessary for him. Therefore, it should not be excluded nor denied. PAE is a reasonable choice in patients with benign prostatic hyperplasia (BPH) and moderate to severe LUTS who wish to preserve erectile and/or ejaculatory function.

The historical standard of care was a more invasive procedure either trans urethral resection of the prostate (TURP) or open surgical prostatectomy. These have both fallen out of favor due to the side-effects, risks of complications and also the longer post-operative recovery times. There are numerous newer minimally invasive procedure options. This patient has a significant medical issue related to symptomatic benign prostate enlargement and meets criteria for treatment. 

The health plan's determination of medical necessity is overturned in whole.