UHC Guideline - Prostate Conditions — BPH, Cancer, PSA Screening

UHC POC Policy Set · effective 2026-01-01 · version v1

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Metadata

Doc IDguideline::uhc::prostate_bph_cancer_v1
PayerUHC
Payer Sluguhc
Topicprostate bph cancer
Document Typepayer_guideline
Chunks5

Covered ICD Codes (12)

N40.0 N40.1 N40.2 C61 R97.20 Z12.5 Z80.42 N42.81 N42.83 N42.9 Z85.46 C77.2

Procedure Keywords (10)

TRUS prostate biopsy transurethral resection of prostate (TURP) PSA screening prostate MRI radical prostatectomy GreenLight laser ablation UroLift Rezum thermal therapy androgen deprivation therapy robotic prostatectomy

Guideline Chunks (5)

Each chunk has its own embedding and is independently retrievable

guideline::uhc::prostate_bph_cancer_v1#chunk0
Section: Coverage intent · Length: 235 chars
Prior authorization may be considered for diagnostic and therapeutic procedures related to benign prostatic hyperplasia (BPH), prostate cancer, and elevated prostate-specific antigen (PSA), when documented medical necessity is present.
guideline::uhc::prostate_bph_cancer_v1#chunk1
Section: Clinical indications that support medical necessity · Length: 591 chars
1. Documented BPH (ICD N40.0, N40.1, N40.2) with lower urinary tract symptoms (LUTS) refractory to medical therapy. 2. Elevated PSA (ICD R97.20) with age-appropriate screening or surveillance indication. 3. Confirmed prostate cancer (ICD C61) requiring active treatment, surveillance imaging, or surgical intervention. 4. Family history of prostate cancer (ICD Z80.42) supporting earlier or more frequent screening. 5. History of prostate cancer (ICD Z85.46) requiring follow-up or recurrence workup. 6. Documented obstructive uropathy or urinary retention secondary to prostate enlargement.
guideline::uhc::prostate_bph_cancer_v1#chunk2
Section: Documentation requirements · Length: 408 chars
1. Recent PSA value and trend over time. 2. Digital rectal exam findings. 3. International Prostate Symptom Score (IPSS) or AUA Symptom Index when applicable. 4. Trial and failure of conservative or pharmacologic therapy (alpha blockers, 5-alpha reductase inhibitors) for BPH cases. 5. Imaging or biopsy results when surgical intervention is requested. 6. Documentation of cancer staging for malignant cases.
guideline::uhc::prostate_bph_cancer_v1#chunk3
Section: Potential reasons for denial or pend · Length: 376 chars
1. Missing PSA values or trend documentation. 2. No documented trial of medical therapy for BPH before requesting surgical intervention. 3. PSA screening requested outside age-appropriate guidelines without high-risk indication. 4. Insufficient symptom severity documentation (IPSS, AUA score). 5. Requested imaging or procedure not aligned with documented diagnosis or stage.
guideline::uhc::prostate_bph_cancer_v1#chunk4
Section: Decision logic · Length: 414 chars
Likely eligible when documented diagnosis aligns with covered ICD codes, conservative therapy has been attempted (for BPH), and clinical documentation supports the requested procedure. Manual review when documentation is incomplete or symptom severity is borderline. Likely not eligible when the requested procedure is screening-only without risk factors, or when no trial of medical therapy is documented for BPH.