Harvard Pilgrim has developed a clinical medical policy on the treatment of benign prostatic hypertrophy, which is a non-cancerous inflammation of the prostate. This policy is effective for dates of service on or after August 1, 2016, and was developed to provide greater clarity on the medical necessity of certain treatments.
Harvard Pilgrim considers the following procedures for the treatment of benign prostatic hypertrophy medically necessary and will continue to cover them:
- Transurethral resection of the prostate (TURP)
- Transurethral incision of the prostate (TUIP)
- Transurethral vaporization of the prostate (TUVP)
- Transurethral enucleation of the prostate (TUEP)
- Transurethral microwave thermotherapy (TUMT)
- Transurethral needle ablation (TUNA), also known as transurethral radiofrequency needle ablation (RFNA)
- Laser prostatectomy and laser-based procedures including contact laser ablation of the prostate (CLAP), holmium laser procedures of the prostate (HoLAP, HoLEP, HoLRP), photoselective laser vaporization (PVP), transurethral ultrasound-guided laser induced prostatectomy (TULIP), and visually guided laser ablation of the prostate (VLAP)
- Water-induced thermotherapy (WIT)
Harvard Pilgrim considers the following procedures (CPT codes 52441, 52442, and 53855) for the treatment of benign prostatic hypertrophy experimental and investigational and will no longer provide coverage for them:
- Transprostatic implants (e.g., Urolift System)
- Insertion of temporary prostatic urethral stent (UroLume)
- Plasma kinetic vaporization
For further information, please refer to the Benign Prostatic Hypertrophy Medical Policy on our provider website and the Non-Covered Services Payment Policy in our online Provider Manual.