Prostate Artery Embolization for Benign Prostatic Hyperplasia

POLICY NUMBER

A.7.01.55

DESCRIPTION

Prostate arterial embolization (PAE) has been investigated as a minimally invasive alternative to transurethral resection of the prostate (TURP), considered the traditional standard treatment for benign prostatic hyperplasia (BPH). PAE differs from other minimally invasive surgical therapies in treatment approach (endovascular vs transurethral) and mechanism (embolic), and thus requires different considerations. An interventional radiologist injects microspheres through a catheter to the blood vessels around the prostate, reducing the blood supply to multiple different areas. No surgical intervention is required for this procedure and recovery times are often less than that of TURP.

Benign prostatic hyperplasia (BPH) is a common condition in older men, affecting to some degree 40% of men in their 50s, 70% of those between ages 60 and 69, and almost 80% of those ages 70 years and older. BPH is a histologic diagnosis defined as an increase in the total number of stromal and glandular epithelial cells within the transition zone of the prostate gland. In some men, BPH results in prostate enlargement which can, in turn, lead to benign prostate obstruction and bladder outlet obstruction, which are often associated with lower urinary tract symptoms (LUTS) including urinary frequency, urgency, irregular flow, weak stream, straining, and waking up at night to urinate. LUTS are the most commonly presenting urological complaint and can have a significant impact on quality of life (QOL).

BPH does not necessarily require treatment. The decision on whether to treat BPH is based on an assessment of the impact of symptoms on QOL along with the potential side effects of treatment. Options for treatment include watchful waiting, medication, and minimally invasive surgical procedures. Patients with persistent symptoms despite medical treatment may be considered for surgical treatment. The traditional standard treatment for BPH is transurethral resection of the prostate (TURP). TURP is generally considered the reference standard for comparisons of BPH procedures. A variety of minimally invasive surgical approaches are available as an alternative to TURP for management of LUTS in men with BPH. These methods include water vapor thermal therapy, prostatic urethral lift, and temporary implanted prostatic devices. Each of these approaches is discussed in detail in separate policies (see Related Policies).

Prostate arterial embolization (PAE) is a minimally invasive treatment option that works by reducing blood supply to prostatic arteries. PAE differs from other minimally invasive surgical therapies in treatment approach (endovascular vs transurethral) and mechanism (embolic), and thus requires different considerations. An interventional radiologist injects microspheres through a catheter to the blood vessels around the prostate, reducing the blood supply to multiple different areas. No surgical intervention is required for this procedure and recovery times are often less than that of TURP. PAE requires significant clinician training and is associated with some common side effects such as post-PAE syndrome, blood in urine or semen, rare cases of prostatic or bladder spasms.

Prostate surgeries are procedures and, therefore, not regulated by the FDA. However, devices and instruments used during the surgery may require FDA approval. Refer to the following website for additional information: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm.

Related medical policies -

• Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation (Aquablation) for Benign Prostatic Hyperplasia

• Prostatic Urethral Lift

• Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic Hyperplasia

POLICY

Prostate artery embolization is considered investigational as a treatment for benign prostatic hyperplasia.

POLICY EXCEPTIONS

Federal Employee Program (FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.

POLICY HISTORY

04/01/2026: New policy added. Approved by the Medical Policy Advisory Committee.

SOURCE(S)

Blue Cross Blue Shield Association policy # 7.01.55

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

Investigational Codes

CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.