Policy title: Prostate Artery Embolization

Policy number: MA 4.051

Effective date: 7/1/2026

Policy

Prostate artery embolization is considered investigational as a treatment for benign prostatic hyperplasia as there is insufficient evidence to support a general conclusion supporting the health outcomes or benefits associated with this procedure.

This medical policy applies specifically to Medicare Advantage plans offered by Capital Blue Cross and its subsidiaries.

Cross-references:
MA 1.147 Prostatic Urethral Lift
MA 1.164 Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic Hyperplasia
MA 4.043 Treatment of the Prostate (Focal, Water Vapor, Aquablation and Hydrogel Spacer)

Description/Background

Benign prostatic hyperplasia (BPH) is a common condition in older men, affecting to some degree 40% of men in their 50s, 70% of those between ages 60 and 69, and almost 80% of those ages 70 years and older. BPH is a histologic diagnosis defined as an increase in the total number of stromal and glandular epithelial cells within the transition zone of the prostate gland. In some men, BPH results in prostate enlargement which can, in turn, lead to benign prostate obstruction and bladder outlet obstruction, which are often associated with lower urinary tract symptoms (LUTS) including urinary frequency, urgency, irregular flow, weak stream, straining, and waking up at night to urinate. LUTS are the most commonly presenting urological complaint and can have a significant impact on quality of life (QOL).

BPH does not necessarily require treatment. The decision on whether to treat BPH is based on an assessment of the impact of symptoms on QOL along with the potential side effects of treatment. Options for treatment include watchful waiting, medication, and minimally invasive surgical procedures. Patients with persistent symptoms despite medical treatment may be considered for surgical treatment. The traditional standard treatment for BPH is transurethral resection of the prostate (TURP). TURP is generally considered the reference standard for comparisons of BPH procedures. A variety of minimally invasive surgical approaches are available as an alternative to TURP for management of LUTS in men with BPH. These methods include water vapor thermal therapy, prostatic urethral lift, and temporary implanted prostatic devices.

Prostate arterial embolization (PAE) is a minimally invasive treatment option that works by reducing blood supply to prostatic arteries. PAE differs from other minimally invasive surgical therapies in treatment approach (endovascular vs transurethral) and mechanism (embolic) and thus requires different considerations. An interventional radiologist injects microspheres through a catheter to the blood vessels around the prostate, reducing the blood supply to multiple different areas. No surgical intervention is required for this procedure and recovery times are often less than that of TURP. PAE requires significant clinician training and is associated with some common side effects such as post-PAE syndrome, blood in urine or semen, rare cases of prostatic or bladder spasms.

Rationale

Summary of evidence

For individuals who have benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) who receive prostate artery embolization (PAE), the evidence includes systematic reviews, randomized controlled trials (RCTs), and noncomparative studies. The outcomes of interest are symptoms, functional outcomes, quality of life, and procedure-related morbidity. A Cochrane meta-analysis of 7 RCTs comparing PAE with transurethral resection of the prostate (TURP) or a sham procedure in men with LUTS due to BPH reported similar improvements in symptom scores and quality of life across procedures over both short-term (≤12 months) and long-term (13-24 months) follow-up. There remained significant uncertainty about major adverse events (very low-certainty evidence), but PAE was associated with a higher likelihood of retreatment (moderate-certainty evidence). The long-term effect on erectile function was minimal (low-certainty evidence), and PAE may continue to lower the incidence of ejaculatory disorders (low-certainty evidence). A qualitative systematic review of 5 RCTs and two observational studies found that PAE and TURP resulted in comparable symptom and quality of life improvements at 12 months. TURP offered greater increases in urine flow and prostate volume reduction, while PAE had shorter hospital stays and fewer complications. Three RCTs, published following the systematic reviews, have assessed the efficacy of PAE relative to conventional therapies for BPH. One RCT conducted in Switzerland (2024) reported that TURP demonstrated superior efficacy to PAE in improving LUTS and urinary flow rates at 5-years of follow-up, although erectile function outcomes favored PAE. Another RCT from Australia (2024) indicated that PAE, when utilized as a first-line therapy, resulted in greater reductions in prostate volume, improved symptom scores, and enhanced quality of life relative to medical therapy, with a lower incidence of adverse events. The third RCT, performed in France (2023), found that PAE was more effective than combined medical therapy for patients with moderate LUTS, yielding greater improvements in both symptoms and erectile function, with no major adverse events and a decreased need for retreatment. All three trials were open-label and characterized by high loss to follow-up and significant patient crossover between study arms. A retrospective, single-center study of 317 men with moderate to severe BPH found bilateral PAE had lower recurrence rates than a unilateral approach at over 2-years of follow-up. There is a paucity of direct comparative data between PAE and other minimally invasive therapies for BPH, such as transurethral vapor thermal therapy, water jet ablation, prostatic urethral lift, and temporary implanted nitinol devices; these modalities are addressed in separate evidence reviews. Future studies should specifically assess outcomes related to repeat interventions and unilateral PAE procedures. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Definitions

Prostate arterial embolization (PAE) has been investigated as a minimally invasive alternative to transurethral resection of the prostate (TURP), considered the traditional standard treatment for benign prostatic hyperplasia (BPH). PAE differs from other minimally invasive surgical therapies in treatment approach (endovascular vs transurethral) and mechanism (embolic) and thus requires different considerations. An interventional radiologist injects microspheres through a catheter to the blood vessels around the prostate, reducing the blood supply to multiple different areas. No surgical intervention is required for this procedure and recovery times are often less than that of TURP.

Disclaimer

Capital Blue Cross’ medical policies are used to determine coverage for specific medical technologies, procedures, equipment, and services. These medical policies do not constitute medical advice and are subject to change as permitted by law or applicable clinical evidence from independent treatment guidelines. Treating providers are solely responsible for medical advice and treatment of members. These policies are not a guarantee of coverage or payment. Payment of claims is subject to a determination regarding the member’s benefit program and eligibility on the date of service, and a determination that the services are medically necessary and appropriate. Final processing of a claim is based upon the terms of contract that applies to the members’ benefit program, including benefit limitations and exclusions. If a provider or a member has a question concerning this medical policy, please contact Capital Blue Cross’ Provider Services or Member Services.

Coding Information

Note: This list of codes is not exhaustive and may change from time to time as permitted by law or applicable clinical guidelines. The inclusion of a code in this section is not a guarantee of coverage or payment. In addition, not all covered services are eligible for separate reimbursement.

Investigational; therefore, not covered:

References

1. UpToDate. Epidemiology and pathophysiology of benign prostatic hyperplasia. Literature review current through: Nov 2025.
2. Mouli S, Salem R, McClure TD. Prostate Artery Embolization for Benign Prostatic Hyperplasia. J Urol. Jul 2024; 212(1): 216-219. PMID 38703386
3. Rosen RC, Cappelleri JC, Smith MD, et al. Development and validation of four-item version of Male Sexual Health Questionnaire to assess ejaculatory dysfunction. Urology. May 2007; 69(5): 805-9. PMID 17489208
4. Cappelleri JC, Rosen RC. The Sexual Health Inventory for Men (SHIM): a 5-year review of research and clinical experience. Int J Impot Res. 2005; 17(4): 307-19. PMID 15875061
5. Sønksen J, Barber NJ, Speakman MJ, et al. Prospective, randomized, multinational study of prostatic urethral lift versus transurethral resection of the prostate: 12-month results from the BPH6 study. Eur Urol. Oct 2015; 68(4): 643-52. PMID 25937539
6. Sarma AV, Wei JT. Clinical practice. Benign prostatic hyperplasia and lower urinary tract symptoms. N Engl J Med. Jul 19 2012; 367(3): 248-57. PMID 22808960
7. O'Leary MP. Validity of the "bother score" in the evaluation and treatment of symptomatic benign prostatic hyperplasia. Rev Urol. 2005; 7(1): 1-10. PMID 16985801
8. Barry MJ, Williford WO, Chang Y, et al. Benign prostatic hyperplasia specific health status measures in clinical research: how much change in the American Urological Association symptom index and the benign prostatic hyperplasia impact index is perceptible to patients?. J Urol. Nov 1995; 154(5): 1770-4. PMID 7563343
9. Roehrborn CG, Wilson TH, Black LK. Quantifying the contribution of symptom improvement to satisfaction of men with moderate to severe benign prostatic hyperplasia: 4-year data from the CombAT trial. J Urol. May 2012; 187(5): 1732-8. PMID 22425127
10. Barry MJ, Fowler FJ, O'Leary MP, et al. Measuring disease-specific health status in men with benign prostatic hyperplasia. Measurement Committee of the American Urological Association. Med Care. Apr 1995; 33(4 Suppl): AS145-55. PMID 7536866
11. Jung JH, McCutcheon KA, Borofsky M, et al. Prostatic arterial embolization for the treatment of lower urinary tract symptoms in men with benign prostatic hyperplasia. Cochrane Database Syst Rev. Mar 29 2022; 3(3): CD012867. PMID 35349161
12. Ini C, Vasile T, Foti PV, et al. Prostate Artery Embolization as Minimally Invasive Treatment for Benign Prostatic Hyperplasia: An Updated Systematic Review. J Clin Med. Apr 25 2024; 13(9). PMID 38731058
13. Sandhu JS, Bixler BR, Dahm P, et al. Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia (BPH): AUA Guideline Amendment 2023. J Urol. Jan 2024; 211(1): 11-19. PMID 37706750
14. Abt D, Müllhaupt G, Hechelhammer L, et al. Prostatic Artery Embolisation Versus Transurethral Resection of the Prostate for Benign Prostatic Hyperplasia: 2-yr Outcomes of a Randomised, Open-label, Single-centre Trial. Eur Urol. Jul 2021; 80(1): 34-42. PMID 33012376
15. Pisco JM, Bilhim T, Costa NV, et al. Randomised Clinical Trial of Prostatic Artery Embolisation Versus a Sham Procedure for Benign Prostatic Hyperplasia. Eur Urol. Mar 2020; 77(3): 354-362. PMID 31831295
16. Insausti I, Saez de Ocariz A, Galbete A, et al. Randomized Comparison of Prostatic Artery Embolization versus Transurethral Resection of the Prostate for Treatment of Benign Prostatic Hyperplasia. J Vasc Interv Radiol. Jun 2020; 31(6): 882-890. PMID 32249193
17. Radwan A, Farouk A, Higazy A, et al. Prostatic artery embolization versus transurethral resection of the prostate in management of benign prostatic hyperplasia. Prostate Int. Sep 2020; 8(3): 130-133. PMID 33102395
18. Abt D, Hechelhammer L, Müllhaupt G, et al. Comparison of prostatic artery embolisation (PAE) versus transurethral resection of the prostate (TURP) for benign prostatic hyperplasia: randomised, open label, non-inferiority trial. BMJ. Jun 19 2018; 361: k2338. PMID 29921613
19. Carnevale FC, Iscaife A, Yoshinaga EM, et al. Transurethral Resection of the Prostate (TURP) Versus Original and PERfeCTED Prostate Artery Embolization (PAE) Due to Benign Prostatic Hyperplasia (BPH): Preliminary Results of a Single Center, Prospective, Urodynamic-Controlled Analysis. Cardiovasc Intervent Radiol. Jan 2016; 39(1): 44-52. PMID 26506952
20. Gao YA, Huang Y, Zhang R, et al. Benign prostatic hyperplasia: prostatic arterial embolization versus transurethral resection of the prostate--a prospective, randomized, and controlled clinical trial. Radiology. Mar 2014; 270(3): 920-8. PMID 24475799
21. Ray AF, Powell J, Speakman MJ, et al. Efficacy and safety of prostate artery embolization for benign prostatic hyperplasia: an observational study and propensity-matched comparison with transurethral resection of the prostate (the UK-ROPE study). BJU Int. Aug 2018; 122(2): 270-282. PMID 29645352
22. Qiu Z, Zhang C, Wang X, et al. Clinical evaluation of embolization of the superior vesical prostatic artery for treatment of benign prostatic hyperplasia: a single-center retrospective study. Videoclin Inter Tech Maloinwazyjne. Dec 2017; 12(4): 409-416. PMID 29362657
23. Müllhaupt G, Hechelhammer L, Graf N, et al. Prostatic Artery Embolisation Versus Transurethral Resection of the Prostate for Benign Prostatic Obstruction: 5-year Outcomes of a Randomised, Open-label, Noninferiority Trial. Eur Urol Focus. Sep 2024; 10(5): 788-795. PMID 38351756
24. Brown N, Kiosoglous A, Castree S, et al. The 'Prostate Embolisation AS first-line therapy Compared to medication in treatment naive men with prostate enlargement: a randomised Controlled trial' (P-EASY ADVANCE): a randomised controlled trial of prostate embolisation vs medication for BPH. BJU Int. Dec 2024; 134 Suppl 2(Suppl 2): 38-46. PMID 39139009
25. Sapoval M, Thiounn N, Desseaux J, et al. Prostatic artery embolisation versus medical treatment in patients with benign prostatic hyperplasia (PARTEM): a randomised, multicentre, open-label, phase 3, superiority trial. Lancet Reg Health Eur. Aug 2023; 31: 100672. PMID 37415648
26. Brown N, Firouzmand S, Kiosoglous A, et al. Prostate artery Embolisation Safety and efficacy: Preliminary and follow-Up urodynamic Studies (P-EASY PLUS). BJU Int. Oct 2025; 136 Suppl 2(Suppl 2): S54-S61. PMID 40501328
27. Carnevale FC, Moreira AM, de Assis AM, et al. Prostatic Artery Embolization for the Treatment of Lower Urinary Tract Symptoms Due to Benign Prostatic Hyperplasia: 10 Years' Experience. Radiology. Aug 2020; 296(2): 444-451. PMID 32484416
28. American Urological Association (AUA). Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA Guideline (Published 2021; Amended 2023).
29. McWilliams JP, Bilhim TA, Carnevale FC, et al. Society of Interventional Radiology Multisociety Consensus Position Statement on Prostatic Artery Embolization for Treatment of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: From the Society of Interventional Radiology, the Cardiovascular and Interventional Radiological Society of Europe, Société Française de Radiologie, and the British Society of Interventional Radiology: Endorsed by the Asia Pacific Society of Cardiovascular and Interventional Radiology, Canadian Association for Interventional Radiology, Chinese College of Interventionalists, Interventional Radiology Society of Australasia, Japanese Society of Interventional Radiology, and Korean Society of Interventional Radiology. J Vasc Interv Radiol. May 2019; 30(5): 627-637.e1. PMID 30926185
30. National Institute for Health and Care Excellence (NICE). Prostate artery embolisation for lower urinary tract symptoms caused by benign prostatic hyperplasia (Interventional procedures guidance; Reference number: IPG611; Published: 25 April 2018).
31. Centers for Medicare & Medicaid Services. NCD: Therapeutic Embolization (20.28).

Policy History

• MP 4.051
  • 01/02/2026 New policy adoption

Plans issued by Capital Blue Cross and it’s subsidiaries are independent licensees of the Blue Cross Blue Shield Association. Communications issued by Capital Blue Cross in its capacity as administrator of programs and provider relations for all companies.

Health care benefit programs issued or administered by Capital Blue Cross and/or its subsidiaries, Capital Advantage Insurance Company^®, Capital Advantage Assurance Company^® and Keystone Health Plan^® Central. Independent licensees of the Blue Cross BlueShield Association. Communications issued by Capital Blue Cross in its capacity as administrator of programs and provider relations for all companies.