Prostate Artery Embolization for Benign Prostatic Hyperplasia
This policy governs coverage and clinical stance for prostate artery embolization (PAE) as a treatment for benign prostatic hyperplasia (BPH) for Premera Bluecross members and informs providers about when the service may be covered or considered investigational.
New policy created declaring prostate artery embolization investigational for treatment of benign prostatic hyperplasia.
Prostate artery embolization added to the Surgery section of policy catalog.
Coverage Determination
Investigational
Covered when ALL of the following are met:
This is the explicit policy coverage determination in this document portion.
Premera Bluecross classifies prostate artery embolization (PAE) as investigational. The policy explicitly states that PAE is considered investigational as a treatment for benign prostatic hyperplasia and therefore is not supported for routine coverage under this policy.
Policy history documents that a new medical policy was created and includes the coverage determination that prostate artery embolization is investigational as a treatment for benign prostatic hyperplasia. The history notes the policy was approved March 10, 2026, with the investigational stance incorporated into the Surgery section.
Coverage criteria state clearly: Prostate artery embolization is considered investigational as a treatment for benign prostatic hyperplasia. As an investigational service, PAE does not meet the policy's criteria for medical necessity.
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