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Benign prostatic hyperplasia (BPH) is a condition which may lead to lower urinary tract symptoms such as urinary frequency, nocturia, urinary hesitancy and feeling of incomplete voiding. Histologic evidence of BPH is present in approximately 50% of men at age 50 and the prevalence increases with advancing age. Glandular overgrowth causes progressive occlusion of the prostatic portion of the urethra in men, and will cause lower urinary tract symptoms to varying degrees. Transurethral resection of the prostate (TURP) is one of the most commonly performed surgeries and is generally well tolerated, but is not without potential complications, such as blood loss (with or without the need for transfusion), retrograde ejaculation and incontinence.  Transurethral resection syndrome is an adverse effect that can occur in up to 2% of cases. The syndrome is caused by absorption of bladder irrigation fluids during the TURP procedure. Depending on the severity, this syndrome can lead to hyponatremia and fluid overload with subsequent neurological and cardiac complications. Less invasive techniques have been investigated using various energy sources, such as laser, direct heat, microwave, radiofrequency and ultrasound. With these techniques, a calculated amount of prostate tissue is destroyed and reabsorbed while leaving the epithelium of the urethral canal relatively intact. This policy addresses the use of microwave energy in the reduction of urethral occlusion and lower urinary tract symptoms.

The goal of microwave thermotherapy is destruction of the prostatic adenoma in the lateral lobes of the prostate to achieve improvement in symptoms and voiding. A transurethral catheter containing a microwave antenna that limits microwave radiation is placed at the prostatic level. Water circulating through the catheter cools the urethra. A Foley-type balloon at the end of the catheter inflates to position the catheter, and fiberoptic sensors are positioned to monitor rectal and urethral temperatures. The correct position of the catheter is verified using transrectal ultrasound of the prostate. The electromagnetic waves emit high-energy photons that interact with molecules in prostatic tissue, producing heat.

Transurethral microwave thermotherapy (TUMT) produces coagulation necrosis of the lateral lobes of the prostate for a distance up to 17 mm from the urethra with the preservation of the urethral surface, distal sphincter, urethral mucosa, bladder neck, and peripheral prostate.

In October 2000, the FDA issued an alert regarding 16 unexpected cases of fistula formation or urethral or penile tissue damage following the use of transurethral microwave thermotherapy devices. In this alert, the FDA recommended ensuring the patient meets criteria for eligible prostate size and had not previously received radiation to the area. It further recommended that the physician remain with the patient throughout the procedure, to verify placement at all times, and to monitor any unusual pain reported. The patient is not to be oversedated.

In December 2002, the “Prostalund® CoreTherm™ System” (Prostalund Operations AB, Concord, MA) was approved by the FDA through the premarket approval (PMA) process for use in men with a prostate size of 30 to 100 grams and prostatic urethra length of 35 mm or greater. Although similar to previous microwave thermotherapy devices, the company sought premarket approval due to the addition of temperature feedback features intended to address the safety concerns noted in the 2000 FDA alert described above.

None

Microwave thermotherapy should not be confused with an earlier technique of microwave treatment, microwave hyperthermia, which has largely been abandoned, and is not eligible for coverage.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

5/8/2001: Code Reference section updated (ICD-9 Procedure code 60.29 & 60.99 deleted; 60.96 added; ICD-9 Diagnosis code 600 range expanded)

5/8/2002: Type of Service and Place of Service deleted

3/12/2004: Code Reference section updated, ICD-9 diagnosis code range 600.0-600.9 (600.00, 600.01, 600.10, 600.11, 600.20, 600.21, 600.3) deleted, ICD-9 diagnosis code 600.90 and 600.91 remain as covered

6/24/2004: Policy reviewed, Policy section "of 35-50 mm" changed to "less than 5 cm", Sources updated

9/19/2006:  Coding revised.  ICD9 2006 revisions added to policy

1/6/2009: Policy reviewed, no changes

09/09/2010: Policy description extensively re-written. Policy statement revised to change the prostatic lengths criteria from "less than 5 cm" to "35-50 mm."

09/23/2011:  Moved the following verbiage from the Policy Statement section to the Policy Guidelines section:  For technical reasons, transurethral microwave thermotherapy (TUMT) is not suitable for patients in whom the prostate gland exceeds 50 mm in length or 70 g in volume), who have median lobe enlargement, or bladder neck stenosis.  Deleted outdated references from the Sources section.

09/27/2012:  Policy reviewed; no changes.

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document.

Covered Codes

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