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MP 7.01.04 Balloon Dilatation of Prostate (Archived)

Medical Policy
Section
Surgery
 
Original Policy Date
12/1/95
Last Review Status/Date
Archived/9:2009
Issue
3:2003
Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.


Description

Balloon dilatation of the prostatic urethra, or balloon urethroplasty, is a therapeutic procedure intended to manage symptoms associated with benign prostatic hypertrophy.

Under fluoroscopic guidance, a flexible balloon catheter is placed in the urethra at the level of the prostate above the external sphincter. The balloon is then inflated for a short period of time to distend the prostatic urethra. This widening process is intended to relieve obstruction of the urethra caused by the enlarged prostate and alleviate the symptoms of benign prostatic hypertrophy (e.g., urinary retention, urgency, hesitancy, nocturia, and dysuria). No surgical specimen is obtained.


Policy

Balloon dilatation of the prostatic urethra is considered investigational.


Policy Guidelines

No applicable information


Benefit Application

BlueCard/National Account Issues

State or federal mandates (i.e., FEP) may dictate that all devices approved by the U.S. Food and Drug Administration (FDA) may not be considered investigational. Therefore, FDA-approved devices may be assessed on the basis of their medical necessity.


Rationale

2003 Update
 
A review of the peer-reviewed literature on MEDLINE from 1995 through June 2003 found no controlled clinical trials on balloon dilatation of the prostate. Based on the paucity of published literature and minimal claim activity reported by plans, it appears that balloon dilatation of the prostate has declined in popularity, in part due to the advent of other minimally invasive treatments of benign prostatic hypertrophy. Given these considerations, this policy is no longer scheduled for routine review.

 

Codes

Number

Description

CPT 

52510 

Transurethral balloon dilatation of the prostatic urethra, any method 

ICD-9 Procedure 

60.95 

Transurethral balloon dilatation of the prostatic urethra 

ICD-9 Diagnosis 

 

Investigational for all codes 

HCPCS 

No code 

Type of Service 

Surgery 

Place of Service 

Inpatient
 
Outpatient
 


Index

Balloon dilatation of the prostatic urethra
Prostatic balloon dilatation
Urethroplasty, balloon dilatation


Policy History

Date Action Reason
12/1/95 Add to Surgery section New policy
04/15/02 Replace policy Policy reviewed without literature search; new review date only
10/9/03 Replace policy Literature review update; policy statement unchanged. No further review scheduled
09/2009 Policy Archived  


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