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Coverage update for surgical and minimally invasive treatments for urinary outlet obstruction due to BPH 

September 27, 2019    

Effective December 2, 2019, AmeriHealth will update its policy regarding surgical and minimally invasive treatments for urinary outlet obstruction due to benign prostatic hyperplasia (BPH) for commercial members. This update is to reflect changes in coverage criteria.

Summary of changes

Here is a summary of the changes that will occur:

  • Transurethral destruction of prostate tissue by radiofrequency generated water vapor thermotherapy (Rezum System) is considered experimental/investigational for commercial members by AmeriHealth and, therefore, not covered because the safety and/or effectiveness in the treatment of urinary outlet obstruction due to BPH has not been established by review of the available published peer-reviewed
  • Prostate artery embolization is considered experimental/investigational for commercial members by AmeriHealth and, therefore, not covered because the safety and/or effectiveness in the treatment of urinary outlet obstruction due to BPH has not been established by review of the available published peer-reviewed
  • Medically necessary coverage language for transurethral needle ablation (TUNA) is removed from the commercial policy. This procedure is no longer recommended per American Urological Association (AUA) guidelines for the treatment of lower urinary tract symptoms (LUTS) attributed to BPH.
  • Simple prostatectomy and transurethral incision of the prostate (TUIP) are considered medically necessary and, therefore, covered when medical necessity criteria are met for commercial members.
  • Coverage of medically necessary procedures will be for individuals 45 years or older with a diagnosis of lower urinary tract symptoms secondary to benign prostatic hypertrophy.
  • Removal of prostate specific antigen (PSA) language from the medical necessity language for prostatic urethral lift (Urolift).

Commercial policy #11.17.06m: Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH) was posted to our Medical Policy Portal as a Notification on September 3, 2019, and will go into effect December 2, 2019.

To view the Notification for this policy, visit our Medical Policy Portal.





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