DESCRIPTION
Water-induced thermotherapy is intended as an option to treat urinary outflow obstruction secondary to benign prostatic hypertrophy. A balloon is inflated within the prostatic urethra. Water, heated to 60 degrees Celsius (140 degrees Fahrenheit), is circulated through the catheter system. The remaining portion of the catheter shaft is insulated and remains at a temperature below 40 degrees Celsius (104 degrees Fahrenheit). The heated water and pressure from the balloon produces deep necrosis within the prostate tissue. The necrotic tissue either sloughs off or is reabsorbed allowing a pathway for the passage of urine. The procedure is performed in the outpatient setting during one session. The individual may require catheterization for at least one week after the procedure, due to sloughing of prostatic tissue.
POLICY
Water-induced thermotherapy for the treatment of benign prostatic hypertrophy is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Any device utilized for this procedure must have FDA approval specific to the indication, otherwise it will be considered investigational.
See also: Balloon Dilatation of the Prostatic Urethra
MEDICAL APPROPRIATENESS
Water-induced thermotherapy for the treatment of benign prostatic hypertrophy is considered medically appropriate if ALL the following criteria are met:
Men over 50 years of age
Prostate length between 2.0 cm and 6.4 cm as determined by ultrasound, rectal examination or endoscopic findings
Urinary outflow obstruction secondary to benign prostatic hypertrophy
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
SOURCES
American Urological Association. (2010). Clinical guidelines. Chapter one: Guideline on the management of benign prostatic hyperplasia (BPH). Retrieved April 15, 2011 from http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines/main-reports/bph-management/chap_1_GuidelineManagementof(BPH).pdf.
BlueCross BlueShield Association. Medical Policy Reference Manual. (1:2003). Water-induced thermotherapy as a treatment of benign prostatic hypertrophy (2.01.49). Retrieved April 15, 2011 from BlueWeb. (4 articles and/or guidelines reviewed)
De la Rosette, J., Gravas, S., & Fitzpatrick, J. M. (2008). Minimally invasive treatment of male lower urinary tract symptoms. Urologic Clinics of North America, 35 (3), 505-518.
Kaplan, S. A. (2006). Update on the American Urological Association guidelines for the treatment of benign prostatic hyperplasia. Reviews in Urology, 8 (Suppl. 4), S10-7.
Turini, G. A., & Pareek, G. (2009). Update on minimally invasive therapies for benign prostatic hyperplasia. Medicine and Health/Rhode Island, 92 (10), 336-338.
U. S. Department of Health and Human Services. National Institutes of Health. (2006, June). Prostate enlargement: Benign prostatic hyperplasia. Retrieved April 15, 2011 from http://kidney.niddk.nih.gov/kudiseases/pubs/pdf/ProstateEnlargement.pdf.
U. S. Food and Drug Administration. (2000, April). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K000508. Retrieved April 15, 2011 from http://www.accessdata.fda.gov/cdrh_docs/pdf/K000508.pdf.
ORIGINAL EFFECTIVE DATE: 12/1/2002
MOST RECENT REVIEW DATE: 5/12/2011
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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