Diagnosis: Benign prostatic hyperplasia (BPH).
Treatment: prostate artery embolization/ambulatory surgery.
The insurer denied coverage for prostate artery embolization/ambulatory surgery.
The denial is overturned.

This case involves a male who was diagnosed with lower urinary tract symptoms, nocturia, increased frequency, urgency, weak stream, and straining and is being considered for prostatic artery embolization (PAE) for benign prostatic hyperplasia (BHP). According to the documentation, the patient was seen and evaluated by a vascular and interventional radiologist who agreed that prostatic artery embolization would be the best treatment option to manage the patient's benign prostatic hyperplasia. The patient previously received a notice of adverse determination regarding the proposed surgery, which indicated that the criteria were not met as the role of the service remains uncertain. It is not fully proven that it improves health outcomes of the usual standard of care and the health plan did not cover investigational (unproven) tests or treatments. The physician is appealing the denial, stating that prostatic artery embolization techniques for treatment of benign prostatic hyperplasia have already been established and once a candidate is deemed eligible for embolization, the choice of embolization modality should lie on the performing physician to be able to use a modality to best serve the patient with comparable efficacy and equal safety. This review is about the coverage of prostate artery embolization/ambulatory surgery.

Literature states that prostatic artery embolization (PAE) is effective and safe for the treatment of men with Lower Urinary Tract Symptoms (LUTS) from benign prostatic hyperplasia in the setting of concomitant, localized, non-obstructive PCA (prostate cancer). The procedure is a minimally invasive procedure for men with benign prostatic hyperplasia that was originally utilized for the treatment of refractory hematuria of prostatic origin. Previously, the patient received a notice of adverse determination for this procedure with claims that it was investigational/experimental, and therefore not covered under the policy. However, the current medical literature has verified that this is now being utilized with effectiveness for the treatment of the patient's condition.

Scientific evidence in peer-reviewed literature supports a result of improvement in health outcomes.

Prostate artery embolization/ambulatory surgery has final approval from the appropriate regulatory bodies for this diagnosis.

The patient is a good candidate for prostate artery embolization/ambulatory surgery.

Prostate artery embolization/ambulatory surgery is one of the best available treatments for this patient at this time.

The adverse risks are not increased over standard treatment/services.

The requested services are likely to be as beneficial or more beneficial than any of the standard treatment/procedures for this patient.

The insurer's denial of prostate artery embolization/ambulatory surgery is overturned.