Prostate Artery Embolization (PAE) is a minimally invasive treatment option for men experiencing symptoms of an enlarged prostate, a condition known as Benign Prostatic Hyperplasia (BPH). The procedure involves blocking the small arteries that supply blood to the prostate gland, causing it to shrink and relieve pressure on the urethra. For those considering PAE, understanding how Medicare handles the cost is a primary concern. Coverage is conditional, as this non-surgical approach lacks a national coverage mandate.
Current Status of PAE Coverage Under Medicare
Prostate Artery Embolization does not have a comprehensive National Coverage Determination (NCD) from the Centers for Medicare & Medicaid Services (CMS). Since an NCD, which would mandate nationwide coverage, is absent, coverage status is not uniform. Medicare Administrative Contractors (MACs), the regional private companies that process Medicare claims, determine coverage based on Local Coverage Determinations (LCDs). These LCDs vary significantly depending on the beneficiary’s geographic location. Providers must confirm the policy of their regional MAC before the procedure to ensure the claim will be approved.
Coverage is typically granted only when PAE is considered medically necessary for treating BPH. This necessity is often established when a patient has moderate to severe Lower Urinary Tract Symptoms (LUTS) that have not improved with standard medical management. PAE is also often covered for patients who are not suitable candidates for traditional surgery, such as Transurethral Resection of the Prostate (TURP), due to advanced age, multiple comorbidities, or an inability to stop taking blood-thinning medications.
Navigating Coverage Based on Medicare Part and Setting
The specific structure of a beneficiary’s Medicare plan and the location where the procedure is performed directly influence how coverage is processed. Since PAE is an outpatient procedure, it is generally covered under Medicare Part B, which covers physician services and outpatient hospital care.
Original Medicare (Part A and Part B) pays for services once they are deemed medically necessary and meet the regional MAC’s criteria. Part B covers the costs associated with the interventional radiologist, facility fees, and supplies. This fee-for-service model dictates that the beneficiary is responsible for cost-sharing after Medicare pays its portion.
Medicare Advantage Plans (Part C) are offered by private insurance companies approved by Medicare. While these plans must cover everything Original Medicare covers, they may have different rules, costs, and network requirements. Part C plans frequently require beneficiaries to obtain prior authorization for procedures like PAE; failure to secure approval can result in a complete denial. The type of facility—such as an Ambulatory Surgical Center (ASC) versus a Hospital Outpatient Department (HOPD)—also affects the final bill, with ASCs often resulting in lower overall facility fees.
Understanding Out-of-Pocket Costs
Even when PAE is covered by Medicare, the beneficiary is responsible for out-of-pocket expenses. Medicare Part B requires the annual deductible ($257 in 2025) be met before coverage begins. Once the deductible is satisfied, the patient is generally responsible for a 20% coinsurance of the Medicare-approved amount for the procedure and related physician services.
The coinsurance obligation results in varying final costs depending on the setting of care. For example, in 2025, the cost for PAE performed at an Ambulatory Surgical Center might be around $1,075, while the cost at a Hospital Outpatient Department could be approximately $1,738. To mitigate these cost-sharing obligations, many beneficiaries enroll in a Medigap policy (Medicare Supplemental Insurance). These policies are designed to cover the deductibles, coinsurance, and copayments that Original Medicare does not pay, significantly reducing the patient’s remaining 20% responsibility.
Steps for Addressing Coverage Denial and Appeals
A denial of coverage for PAE is not necessarily the final word, as beneficiaries have the right to appeal Medicare’s decision. For those with Original Medicare, the initial step is a Redetermination, involving a review by the regional Medicare Administrative Contractor (MAC). The appeal must be filed in writing, usually within 120 days of receiving the denial notice.
It is helpful to include strong supporting documentation, such as a detailed letter of medical necessity from the treating physician. This letter should clearly explain why PAE is the most appropriate treatment given the patient’s symptoms or contraindications to other procedures.
The Medicare appeals process is multi-level, allowing progression to a review by a Qualified Independent Contractor (QIC) if the initial redetermination is unfavorable. The process for Medicare Advantage (Part C) plans follows a similar structure but begins with a Reconsideration by the private insurance company itself. Patients can also seek assistance from their State Health Insurance Assistance Program (SHIP) for guidance through the appeal stages.