Diagnosis: Benign Prostatic Hyperplasia
Treatment: Prostate Aquablation (code 042IT)
The insurer denied: Prostate Aquablation (code 042IT)
The denial is upheld

The patient is an adult male with a diagnosis of benign prostatic hyperplasia with urinary obstruction. Detailed medical information including associated symptoms, prior therapy and
prostate anatomy information is unknown. Medical appropriateness for Aquablation of the prostate is under review.

The health plan should not cover the proposed treatment.
Aquablation is a novel procedure for management of benign prostatic hyperplasia. The Aquablation procedure uses a targeted high velocity saline stream to ablate prostatic tissue
without generation of thermal energy under real-time ultrasound guidance. Current medical literature is limited with a few studies with limited long-term outcomes. As such use of aquablation is not considered a clinically appropriate and generally acceptable standard of care for managing patients with benign prostatic hyperplasia. Hence, it would be considered experimental and not medically appropriate. American Urological Association guidelines on benign prostatic hyperplasia, 2019 states "Aquablation may be offered to patients with lower urinary tract symptoms (LUTS) attributed to BPH (benign prostatic hyperplasia) provided prostate volume is more than 30 g (grams) and less than 80 g, however, patient should be informed in long-term evidence of efficacy and retreatment rates, remain limited."

European Association of Urology guidelines on management of nonneurogenic male urinary tract symptoms, 2019 states "The first clinical experience provides encouraging results, with a low risk of sexual dysfunction, but further modifications of the aqua beam cystoscopy may be necessary. Long-term follow-up will help us assess the clinical value of Aquablation."

In addition, detailed medical information regarding prior therapy, prostate volume and associated symptoms is largely unknown. As such the requested procedure would not be considered clinically appropriate and generally excepted standard for management of this patient's medical condition. Hence it would be considered experimental/investigational.