Point32 Procedures for the Treatment of Benign Prostatic Hypertrophy (BPH)(Eff. beginning 1.1.24) Form

The Plan uses guidance from the Centers for Medicare and Medicaid Services (CMS) for coverage determinations for its Medicare Advantage plan members. CMS National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Local Coverage Articles (LCAs) and documentation included in the Medicare manuals are the basis for coverage determinations.

For Tufts Health One Care plan members the following LCDs are being used:
Rezum LCD - Water Vapor Thermal Therapy for LUTS/BPH (L37808) (cms.gov)
Cryoablation, Prostate: For Cryoablation of the prostate the NCD - Cryosurgery of Prostate (230.9) (cms.gov) is being supplemented by InterQual to allow for coverage for initial treatment of prostate cancer.

For all other procedures, evidence is sufficient for coverage. The use of InterQual provides guidance for the coverage of these additional BPH procedures. The guidance for the use of this expanded criteria for these indications is supported by the American Urological Association.

The use of this criteria in the utilization management process will ensure access to evidence based clinically appropriate care. See References section below for all evidence accessed in the development of these criteria.

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

Codes