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Medical Policy

Policy Num:      07.001.024
Policy Name:    Transurethral Radiofrequency Needle Ablation of the Prostate
Policy ID:          [07.001.024]  [Ar / B / M+ / P]  [7.01.59]

Last Review:      May 8, 2019
Next Review:      Policy Archived
Issue:                  5:2019

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Related Policies BCBS: None

Related Policies TSSS: None

Transurethral Radiofrequency Needle Ablation of the Prostate

Summary

Transurethral radiofrequency needle ablation of the prostate (also known as TUNA or RFNA) of the prostate has been proposed as an alternative to transurethral resection of the prostate (TURP) for treatment of benign prostatic hyperplasia (BPH). Other alternatives include transurethral incision of the prostate, intraurethral stents, balloon dilation, heat therapy (e.g., microwave hyperthermia), high-intensity focused ultrasound (HIFU), roller ball transurethral vaporization of the prostate, and laser prostatectomy. The mechanism of TUNA is thermal coagulation necrosis. The TUNA procedure is performed under direct vision. The intraurethral components are contained in a sheath, including 2 flexible needles that are deployed into the lateral lobes of the prostate adenoma to a depth determined by transrectal ultrasound measurement. Each lobe is treated 2 to 4 times, and the procedure averages 30 minutes in length.

Objective

The objective of this policy is to compare  the functional outcomes and the treament related  morbidity

Policy Statements

Transurethral radiofrequency needle ablation of the prostate (TUNA) may be considered medically necessary as a treatment of benign prostatic hypertrophy.

Candidates for this procedure are men over 45 years of age with a Prostate with an estimated weight of 80 grams or less, volume of 90 ml or less, with a flow maximum urinal of less than 12cc per second and the urine volume is less than 300cc. Hyperplasia should be predominantly in the lateral lobes and that

demonstrate the symptoms described above for more than three months.

Those patients in whom TURP is contraindicated are included as candidates, tales like anticoagulated patients, hemophiliacs, patients with serious problems cardiovascular or respiratory and very old patients.

Radiofrequency ablation of the prostate is considered for payment as expressed in this policy.

Policy Guidelines

In 1998, a new CPT code was introduced (53852), which specifically describes transurethral radiofrequency needle ablation of the prostate.

Benefit Application

BlueCard/National Account Issues

N/A

Background

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Regulatory Status

N/A

Rationale

This policy is based on a 1998 TEC Assessment (1), which offered the following conclusions:

• Clinical series that includes a total of 910 patients consistently reports decreases in symptoms and demonstrates improvement in urodynamic measures such as peak maximal flow and postvoiding residual 3–6 months after radiofrequency needle ablation (RFNA).
• A randomized clinical trial has also been published, comparing RFNA with TURP. The results from the clinical trial report significant symptomatic and urodynamic improvement with both treatments showing improvement. Although TURP produced greater improvement in symptoms and urologic functions, the average American Urological Association symptoms score for patients who underwent RFNA improved from severe to the moderate range of BPH symptoms severity. Adverse events associated with RFNA were transient and significantly less than for TURP. In addition, RFNA did not produce the harmful outcomes related to blood transfusion and postTURP syndrome.

Population Reference No. 1 

The results from the clinical trial report significant symptomatic and urodynamic improvement with both treatments showing improvement. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Supplemental Information

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Practice Guidelines and Position Statements

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Medicare National Coverage

N/A

References

1. 1998 TEC Assessment, Tab 25

Codes

Appplicable Modifiers

N/A

Policy History