Do not make financial decisions based on this page alone. Medicare has no PAE-only national or local coverage policy. A plan can still set its own rules. Check with your insurer and the radiology office before you schedule.

Key facts

  • Medicare has no PAE-specific national coverage decision. The general therapeutic embolization policy, NCD 20.28, applies.
  • No local coverage determinations or local billing articles were found for PAE.
  • PAE has no dedicated CPT code. It is billed under 37243, the general embolization code.
  • UnitedHealthcare Medicare Advantage adds its own criteria on top of that general policy.
  • Some commercial plans still call PAE investigational. A Premera policy updated in March 2026 does not cover it.

Start by confirming PAE is being discussed for your situation

Before you spend time on coverage, ask whether PAE is a reasonable option for your symptoms, prostate shape, and health. A bill that gets paid does not mean a procedure is a good fit. It's worth discussing PAE with both a urologist and an interventional radiologist. Compare PAE vs TURP, PAE vs Rezum and UroLift, and PAE success and retreatment on the dedicated guides, or open BPH treatment options for a side-by-side list.

Questions to ask

  • Based on my prostate size, median lobe anatomy, symptom severity, and other health factors, is PAE a reasonable option to discuss?
  • Should I also be discussing medications, minimally invasive urology procedures (UroLift, Rezum, Aquablation), TURP, or other surgical options to have a full comparison?
  • If PAE is worth discussing, what pictures and lab tests does the radiology team need before that visit is useful?

Why this matters: Some people start with the bill and later learn PAE was not a good fit for their prostate or health. It is kinder to have that talk first, then ask about Medicare.

Ask about the billing code and coverage policy

PAE has no dedicated CPT code. It is billed under 37243, the general code for embolization for a tumor or for reduced blood flow to an organ1. A 2020 radiology paper set a reporting standard. It did not create a new PAE code2.

Diagnosis codes that have been used include N40.1, enlarged prostate with urinary symptoms, sometimes with R31.0, visible blood in the urine. At least one Medicare Advantage plan's coders challenged 37243 for PAE, saying the record lacked a tumor or loss of blood flow, and suggested 37242 instead. Coding experts disagree with that view3.

Medicare has no PAE-specific national coverage decision. The general therapeutic embolization policy, NCD 20.28, applies. A UnitedHealthcare Medicare Advantage policy reports that no local coverage determinations or local billing articles exist for PAE4.

Questions to ask

  • Does your practice accept Medicare assignment for PAE, and which Medicare plans do you participate with?
  • Will the claim use CPT 37243, and which diagnosis code, such as N40.1, will be sent?
  • If a coder questions 37243 and suggests 37242, how does the office respond?
  • Does my plan follow only the general embolization policy, or does it add its own medical-necessity criteria?
  • If I have Medicare Advantage, is your practice in network for this procedure?

Why this matters: There is no PAE-only local Medicare rule that changes by state. The code and the plan's own criteria are the practical questions. Ask which billing codes the office will send.

Codes your bill may show

A bill, an estimate, or an explanation of benefits lists numeric procedure codes. A code names a service. It does not say that Medicare or your plan will pay for it.

A code you may see on PAE paperwork is CPT 37243, as the section above explains. A January 2020 CMS document (MLN MM11605) prints it as vascular embolization or occlusion, with the imaging included, “for tumors, organ ischemia, or infarction”9. CMS’s 2026 Physician Fee Schedule relative value file (RVU26D, October 2026 release) lists 37243 as an active code12. You can search a procedure code in the CMS Physician Fee Schedule Look-Up Tool10.

“Therapeutic embolization” is the name of Medicare’s general policy, NCD 20.28. It covers embolization for hemorrhage, and for other conditions the procedure can treat, when reasonable and necessary for the individual patient11. The text does not name PAE or the prostate, and it lists no procedure codes. Wording on a statement can differ from plan to plan, so ask the office to explain any line you do not recognize.

Why this matters: A code on a bill is not a coverage promise. Medicare’s coverage rules or your plan’s own rules, including whether it requires prior authorization, decide whether it pays. If you have Medicare Advantage or another plan, ask that plan about its rules before treatment, and keep the answer in writing.

Check your specific Medicare plan details

After you pay the Part B deductible, you usually pay 20% of the cost for each Medicare-covered service or item if your provider accepts assignment5. That is a general Part B rule, not a PAE price. A Medicare Advantage plan can add its own medical-necessity criteria. UnitedHealthcare Medicare Advantage adds its own criteria on top of NCD 20.284. Some commercial plans still call PAE investigational, which means it is not covered. Premera policy 7.01.55, updated March 2026, is one example1.

Questions to ask

  • Do I have Original Medicare (Part B) or a Medicare Advantage plan, and do the rules differ for PAE?
  • Has my Part B deductible been met for the year, and what is my remaining out-of-pocket exposure?
  • If I have a Medigap (Medicare Supplement) plan, does it cover the 20% coinsurance that Part B does not cover?
  • If I have Medicare Advantage, is the interventional radiology practice in network, and does the plan add its own criteria on top of Medicare's general embolization policy?
  • If I have a commercial plan rather than Medicare, does that plan still call PAE investigational?

Why this matters: Original Medicare and Medicare Advantage work differently. An Advantage plan can add its own medical-necessity criteria even when the general embolization policy applies. A commercial plan can call PAE investigational and not cover it. Extra plans that fill the gap, sometimes called Medigap, also differ. Some pay the 20% that Part B leaves, and some leave you with a copay. Knowing which card you have changes the questions.

What to gather before you call

Before you call, it helps to know whether you have Original Medicare Part B or a Medicare Advantage plan. Ask which billing code the office will send, and whether the plan follows only the general embolization policy. A coverage answer still does not say whether PAE fits your prostate or your symptoms.

Whether PAE is a reasonable option is a clinical question. Read PAE versus TURP and surgery, PAE versus Rezum and UroLift, PAE success and retreatment, and questions to ask before PAE before you treat a coverage answer as a treatment decision. The BPH article library covers each option in depth, the BPH treatment options page lists medicines and procedures side by side, and the PAE recovery guide covers the days and months afterward.

What to ask if coverage is denied or unclear

If the plan says PAE is not covered, or the office tells you coverage is uncertain, you have options. Original Medicare has five appeal levels: redetermination by your Medicare Administrative Contractor, reconsideration by an independent contractor, a hearing with an administrative law judge, review by the Medicare Appeals Council, and federal court. Medicare.gov lists these five levels6. Your care team can help you gather records for an appeal.

Questions to ask

  • What was the specific reason for the denial, and is it based on medical necessity, coding, network, or lack of documentation?
  • Can the IR team submit a redetermination (appeal) with additional clinical notes, imaging findings, or supporting literature?
  • Would having the procedure performed in a hospital outpatient department versus an ambulatory surgery center affect coverage?
  • If PAE is not covered under my plan, what are my options — self-pay, financing, or discussing a clinically similar alternative?
  • Is the denial from Original Medicare's general embolization policy, or from my plan's own criteria? A cited Medicare Advantage policy found no PAE-only local coverage determination.

Why this matters: A first no is not always the last word. Some denials are reversed on appeal when more documentation is provided. Ask them to explain the next step in plain language. You do not have to learn the whole appeal system yourself.

Common questions

Does Medicare cover prostate artery embolization (PAE)?

Medicare has no PAE-specific national coverage decision. The general therapeutic embolization policy, NCD 20.28, applies, and no local coverage determinations or local billing articles were found for PAE. PAE has no dedicated CPT code. It is billed under 37243, the general embolization code. Medicare Advantage plans can add their own medical-necessity criteria. Checking your specific plan is essential. This page does not guarantee coverage.

Does Original Medicare pay the whole PAE bill?

After you pay the Part B deductible, you usually pay 20% of the cost for each Medicare-covered service or item if your provider accepts assignment5. That is a general Part B rule, not a PAE price. A Medigap plan may cover some or all of that share, or it may leave a copay. Ask whether your deductible has been met and what your plan pays.

Does Medicare Advantage cover PAE the same way?

Medicare has no PAE-only national or local policy, but a Medicare Advantage plan can add its own medical-necessity criteria. UnitedHealthcare Medicare Advantage adds its own criteria on top of the general embolization policy. Some commercial plans, such as one Premera policy updated in March 2026, still call PAE investigational and do not cover it. Ask your own plan.

What code is used to bill PAE?

PAE has no dedicated CPT code. It is billed under 37243, the general embolization code. A 2020 radiology reporting standard did not create a new PAE code. Diagnosis codes that have been used include N40.1, sometimes with R31.0. Some Medicare Advantage coders have argued for 37242 instead. Coding experts disagree.

What can I do if Medicare denies PAE?

Original Medicare has five appeal levels: redetermination by your Medicare Administrative Contractor, reconsideration by an independent contractor, a hearing with an administrative law judge, review by the Medicare Appeals Council, and federal court. Medicare.gov lists these five levels6. Some denials are reversed on appeal when more documentation is provided. Ask the care team to explain the next step in plain language.

Does coverage mean PAE is the right procedure?

A bill that gets paid does not mean a procedure is a good fit. It's worth discussing PAE with both a urologist and an interventional radiologist. Ask about fit before you spend time on Medicare.

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Sources

  1. Premera policy 7.01.55, 2026 ↩︎
  2. JVIR reporting standard, 2020 ↩︎
  3. PAE coding Q&A, 2022 ↩︎
  4. UnitedHealthcare Medicare Advantage prostate services policy, 2026 ↩︎
  5. Medicare.gov costs ↩︎
  6. Medicare.gov appeals in Original Medicare ↩︎
  7. Medicare.gov Surgery Coverage
  8. CMS Medicare Coverage Database
  9. CMS, MLN Matters MM11605, January 2020 OPPS update (prints the CPT 37243 wording) ↩︎
  10. CMS Physician Fee Schedule Look-Up Tool overview ↩︎
  11. CMS National Coverage Determination 20.28, Therapeutic Embolization ↩︎
  12. CMS, 2026 Physician Fee Schedule relative value file RVU26D, October 2026 release (lists CPT 37243 as an active code) ↩︎