TUFTS Health Plan Harvard Pilgrim HealthCare

Medical Necessity Guidelines: Procedures for the Treatment of Benign Prostatic Hypertrophy (BPH)
Effective: August 1, 2023

Prior Authorization Required

If REQUIRED, submit supporting clinical documentation pertinent to service request.

• Yes
• No

Notification Required

IF REQUIRED, concurrent review may apply

• Yes
• No

Applies to:

Commercial Products

• Harvard Pilgrim Health Care Commercial products; 800-232-0816
• Tufts Health Plan Commercial products; 617-972-9409

CareLinkSM – Refer to CareLink Procedures, Services and Items Requiring Prior Authorization

Public Plans Products

• Tufts Health Direct – A Massachusetts Qualified Health Plan (QHP) (a commercial product); 888-415-9055
• Tufts Health Together – MassHealth MCO Plan and Accountable Care Partnership Plans; 888-415-9055
• Tufts Health RITogether – A Rhode Island Medicaid Plan; 857-304-6404
• Tufts Health Unify* – OneCare Plan (a dual-eligible product); 857-304-6304

*The MNG applies to Tufts Health Unify members unless a less restrictive LCD or NCD exists.

Senior Products

• Harvard Pilgrim Health Care Stride Medicare Advantage; 866-874-0857
• Tufts Health Plan Senior Care Options (SCO), (a dual-eligible product); 617-673-0965
• Tufts Medicare Preferred HMO, (a Medicare Advantage product); 617-673-0965
• Tufts Medicare Preferred PPO, (a Medicare Advantage product); 617-673-0965

Note: While you may not be the provider responsible for obtaining prior authorization or notifying Point32Health, as a condition of payment you will need to ensure that any necessary prior authorization has been obtained and/or Point32Health has received proper notification. If notification is required, providers may additionally be required to provide updated clinical information to qualify for continued service.

For Harvard Pilgrim Health Care Members:

This policy utilizes InterQual® criteria and/or tools, which Harvard Pilgrim may have customized. You may request authorization and complete the automated authorization questionnaire via HPHConnect at www.harvardpilgrim.org/providerportal. In some cases, clinical documentation may be required to complete a medical necessity review. Please submit required documentation as follows:

Providers may view and print the medical necessity criteria and questionnaire via HPHConnect for providers (Select Research and the InterQual® link) or contact the commercial Provider Service Center at 800-708-4414. (To register for HPHConnect, follow the instructions here). Members may access materials by logging into their online account (visit www.harvardpilgrim.org, click on Member Login, then Plan Details, Prior Authorization for Care, and the link to clinical criteria) or by calling Member Services at 888-333-4742

For Tufts Health Plan Members:

To obtain InterQual® SmartSheetsTM
"Tufts Health Plan Commercial Plan products: If you are a registered Tufts Health Plan provider click here to access the Provider Website. If you are not a Tufts Health Plan provider, please click on the Provider Log-in and

+ az . Point32Health com pa nies2158565
Procedures for the Treatment of Benign Prostatic Hypertrophy

• follow instructions to register on the Provider website or call Provider Services at 888-884-2404

Tufts Health Public Plans products: InterQual® SmartSheet(s) available as part of the prior authorization process

Tufts Health Plan requires the use of current InterQual® Smartsheet(s) to obtain prior authorization. In order to obtain prior authorization for procedure(s), choose the appropriate InterQual® SmartSheet(s) listed below.

The completed SmartSheet(s) must be sent to the applicable fax number indicated above, according to Plan

Clinical Guideline Coverage Criteria

The Plan requires the use of InterQual® Subsets or SmartSheets for prior authorization for the following procedures:

• Prostatectomy, Transurethral Resection (TURP)
• Prostatectomy, Transurethral Ablation
  • Photoselective Vaporization of the Prostate (PVP)
  • Transurethral Holmium Laser Ablation of the Prostate (HoLAP)
  • Transurethral Microwave Thermotherapy (TUMT)
• Cryoablation, Prostate

Additional Clinical Coverage Criteria

Urethral Lift

The Plan may authorize a prostatic urethral lift approach (e.g., Urolift®) When InterQual criteria for Prostatectomy, Transurethral Resection are met.

Water Vapor Thermal Therapy

The Plan considers water vapor thermal therapy (Rezūm System) as reasonable and medically necessary for the treatment of moderate to severe lower urinary tract symptoms in benign prostatic hyperplasia (BPH) when ALL of the following criteria are met:

1. The Member is 50 years of age or older;
2. Testing confirms the Member does not have a diagnosis of prostate cancer and there are no contraindications to the procedure (e.g., active urinary tract infection, recent prostatitis, neurogenic bladder, prior prostate surgery, active urethral stricture);
3. Estimated Prostate volume of ≥ 30 and < 80 cc;
4. Failure, contraindication or intolerance to at least three months of pharmacologic therapy for BPH (e.g., alpha-1-adrenergic antagonist, PDE5 Inhibitor, finasteride/dutasteride)

Note: Repeat use of transurethral water vapor thermal therapy for treatment of BPH is considered investigational

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