Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate artery embolization (PAE). 
 
You asked the Plan to pre-approve prostate artery embolization (PAE). You say that you have tried treating 
benign prostatic hyperplasia (BPH) with supplements and then with Tamsulosin, which was not only 
ineffective but you could not tolerate the side effects. You say that you found a urologist, and upon 
examination of your prostate, he felt that your prostate was too large for a urolift and suggested transurethral 
resection of the prostate (TURP). You say it was excruciatingly painful due to being catheterized and within 
two days you were admitted to the hospital with a pulmonary embolism and BPH symptoms have returned. The 
Plan denied your request. The Plan says prostate artery embolization (PAE) is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve prostate artery embolization (PAE). Our reviewer says that the requested prostate artery embolization (PAE) is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that prostatic arterial embolization (PAE) is considered an 
experimental technique to treat symptomatic BPH. Very limited studies have demonstrated possible short-term 
safety and efficacy. The most recent American Urological Association (AUA) guidelines do not recommend 
this procedure outside of a clinical trial setting due to the heterogeneity in the available literature and safety 
concerns regarding radiation exposure, postembolization syndrome, vascular access, technical feasibility, 
higher clinical failure rate compared with more traditional methods (e.g., transurethral resection of the prostate 
[TURP]). The 2023 AUA Guideline update states: PAE may be offered for the treatment of LUTS/BPH. PAE 
should be performed by clinicians trained in this interventional radiology procedure following a discussion of 
the potential risks and benefits. (Conditional Recommendation: Evidence level: Grade C). The Panel was 
unable to find substantial evidence to recommend PAE over more widely available minimally invasive surgical 
therapies (MISTs) for the routine treatment of LUTS, but there is evidence showing a short-term benefit of 
PAE compared to observation in a very select patient population. The Panel recommends continued 
investigation of PAE through trials involve multi-disciplinary teams of urologists and radiologists focused on 
further defining specific indications, including but not limited to gross hematuria recalcitrant to other therapies. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prostate artery embolization (PAE) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve prostate artery embolization (PAE).