Prostate Artery Embolization
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This policy governs coverage and medical necessity criteria for prostate artery embolization (PAE) to treat benign prostatic hyperplasia (BPH) and related lower urinary tract symptoms for members of Johns Hopkins Health Plans lines of business.
New policy created for Prostate Artery Embolization.
Coverage and Medical Necessity
Medical necessity for Prostate Artery Embolization
Covered when ALL of the following are met:
From policy criteria
Section IV.1
Section IV.2
Coverage when policy criteria met
Policy covers PAE when MPAC-approved clinical criteria are met (see full policy for detailed criteria).
Detailed criteria are in the full policy body.
PAE is considered not medically necessary for all other indications that are not explicitly listed in the policy's clinical criteria. This means that unless a member meets the specific documentation and clinical indication requirements described in the policy (e.g., BPH with moderate to severe LUTS plus one of the enumerated qualifying conditions), requests for PAE for other diagnoses or presentations will not meet medical necessity per this policy.
The document fragment provided does not enumerate additional explicit exclusion conditions beyond the general noncoverage statement; however, the revision history indicates this is a new policy (approved 04/21/2026, effective 07/01/2026). Providers should consult the full policy text for any comprehensive exclusion language that may appear elsewhere in the complete policy document.
Coverage for PAE is contingent upon the member meeting the policy's criteria and the member's contract providing benefits for the procedure. Per policy language, unless specific benefits are provided under the member's contract, PAE is not medically necessary for indications other than those listed in the clinical criteria.
The current document excerpt does not contain detailed 'not medically necessary' statements beyond the general guidance; because this is a newly created policy, reviewers and providers should refer to the full policy body for the complete list of NMN determinations and any operational definitions that guide denial or coverage decisions.
Billing and Code References
| affected codes | Policy indicates affected codes for prior authorization and billing are specified in the policy. |
Provider Responsibilities and Authorization
Preauthorization required for inpatient admissions; informational CPT codes
All inpatient admissions for PAE require preauthorization. The coding section lists CPT codes 37242 and 37243 for informational purposes only.
- Note: Inclusion of CPT codes does not guarantee coverage or payment; verify member benefits.
Prior authorization required for PAE under new policy
This is a new policy establishing coverage rules and prior authorization requirements for prostate artery embolization; affected billing codes for prior authorization are specified in the policy.
- See policy CMS24.31 for the full list of affected prior authorization/billing codes.
Document prior medical therapy failure, contraindication, or refusal
Documentation must show that prior medical therapy failed, was contraindicated, or was refused before PAE is considered medically necessary.
- Clinical notes should explicitly state the nature and duration of prior medical therapy and the reason it was unsuccessful, contraindicated, or declined.
Policy cites clinical guidelines and comparative trials
The policy references guideline documents and randomized and observational trials that position PAE as a management option within the context of other treatments for BPH.
- Examples cited include the SIR multisociety consensus statement and randomized trials such as PARTEM and other comparative studies.
Required clinical documentation for prior authorization
Prior authorization requests must include clinical notes confirming BPH diagnosis, IPSS, relevant urologic history, prostate sizing (e.g., ultrasound, MRI, CT), and the clinical rationale for selecting PAE.
- Documentation must also state that the procedure will be performed by an interventional radiologist or equivalent specialist with PAE expertise.
- Include objective prostate gland sizing test results and IPSS score values.
Policy reviewed and approved by MPAC — follow MPAC criteria
This policy was reviewed and approved by the Medical Policy Advisory Committee (MPAC); providers should follow MPAC-defined clinical review criteria in the policy.
- MPAC approval date: 04/21/2026; Policy effective date: 07/01/2026.
Risk of denial for lack of preauthorization
Failure to obtain required preauthorization for inpatient admissions may result in denial or require additional review.
- Adherence may be monitored and addressed through post-payment data analysis and medical review audits.
Enforcement and denial risk under newly created policy
New policy created and approved by MPAC; not meeting the newly specified policy criteria may result in denial per MPAC-approved policy.
- Providers should ensure documentation meets all criteria specified in CMS24.31 to avoid coverage denial.
Clinical Background
Prostate artery embolization (PAE) is a minimally invasive endovascular procedure performed by interventional radiology techniques that selectively embolizes prostatic arteries to reduce blood flow to the gland, causing ischemic shrinkage and symptomatic relief of lower urinary tract symptoms from benign prostatic hyperplasia. The policy release notes this is a new MPAC‑approved policy (approval 04/21/2026; effective 07/01/2026) establishing criteria and coverage rules for the procedure.
Key Terms and Scores
Policy Changes and Approval
Policy reviewed and approved by the Medical Policy Advisory Committee (MPAC) on 04/21/2026 (signature on file).
New policy for Prostate Artery Embolization (Policy No. CMS24.31) was created and approved by MPAC on 04/21/2026, with an effective date of 07/01/2026.
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