Prostatic Stent - Temporary Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 05|04|2010 POLICY LAST REVIEWED: 01|07|2026 OVERVIEW This policy documents the coverage determination for temporary prostatic stents. Prostatic obstruction is a common condition with a variety of etiologies. Obstruction may also occur acutely after surgical treatment for benign prostatic hyperplasia (BPH), prostatic cancer, or after radiation therapy. Intraprostatic stenting has been investigated as a short-term treatment option, permitting volitional urination as an alternative to the commonly used Foley catheter, in which urine is collected in an external bag.
Note: This policy does not address the use of permanent prostatic stents. The policy only addresses temporary stents, which are designed to be removable. MEDICAL CRITERIA Not applicable PRIOR AUTHORIZATION Not applicable POLICY STATEMENT Medicare Advantage Plans Temporary prostatic stents are covered. Note: Blue Cross & Blue Shield of Rhode Island (BCBSRI) must follow Centers for Medicare and Medicaid Services (CMS) guidelines, such as National Coverage Determinations (NCD) or Local Coverage Determinations (LCD) for all Medicare Advantage Plan policies. Therefore, Medicare Advantage Plan policies may differ from Commercial Products. In some instances, benefits for Medicare Advantage Plans may be greater than what is allowed by the CMS. Commercial Products Temporary prostatic stents are not medically necessary as the evidence is insufficient to determine the effects of the technology on health outcomes. COVERAGE Benefits may vary between groups/contracts. Please refer to the appropriate section of the Benefit Booklet, Evidence of Coverage or Subscriber Agreement for services not medically necessary. BACKGROUND Prostatic obstruction is a common condition with a variety of etiologies. Obstruction may also occur acutely after surgical treatment for benign prostatic hyperplasia (BPH), prostatic cancer, or after radiation therapy. Intraprostatic stenting has been investigated as a short-term treatment option, permitting volitional urination as an alternative to the commonly used Foley catheter, in which urine is collected in an external bag. In addition to volitional urination, the ideal temporary stent would be one that could be easily inserted and removed without migration, permitting adequate emptying of the bladder without disrupting the external sphincter such that continence could be maintained. Regulatory Status Medical Coverage Policy | Prostatic Stent - Temporary

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

The Spanner™ (AbbeyMoor Medical, Parkers Prairie, MN) temporary stent is composed of a proximal balloon to prevent distal displacement, a urine port situated cephalad to the balloon, and a reinforced stent of various lengths to span most of the prostatic urethra. The insertion of this device may be as an outpatient procedure with the patient under topical anesthesia or as an office procedure without anesthesia.
In December 2006, the device “The Spanner™” (AbbeyMoor Medical) was approved by the Food and Drug Administration (FDA) through the premarket approval process for temporary use (up to 30 days) to maintain urine flow and allow voluntary urination in patients following minimally invasive treatment for BPH and after initial post-treatment catheterization. Data are inconclusive regarding the role of temporary prostatic stents for prostatic obstructive conditions. This procedure has not been shown to improve the net health outcome. Therefore, the use of temporary prostatic stents is considered not medically necessary for Commercial members as there is no proven efficacy. Temporary prostatic stents are considered medically necessary for Medicare Advantage Plan members.
CODING Medicare Advantage Plans and Commercial Products The following code(s) are covered for Medicare Advantage Plans and not medically necessary for Commercial Products:
53855 Insertion of a temporary prostatic urethral stent, including urethral measurement

RELATED POLICIES Not applicable

PUBLISHED Provider Update, March 2026 Provider Update, April 2025 Provider Update, September 2024 Provider Update, April 2023 Provider Update, July 2022

REFERENCES

1. Dineen MK, Shore ND, Lumerman JH et al. Use of a temporary prostatic stent after transurethral microwave thermotherapy reduced voiding symptoms and bother without exacerbating irritative symptoms. Urology 2008; 71(5):873-7.
2. Grimsley SJ, Khan MH, Lennox E et al. Experience with the spanner prostatic stent in patients unfit for surgery: an observational study. J Endourol 2007; 21(9):1093-6.
3. Kijvikai K, van Dijk M, Pes PL et al. Clinical utility of "blind placement" prostatic stent in patients with benign prostatic obstruction: a prospective study. Urology 2006; 68(5):1025-30.
4. van Dijk MM, Mochtar CA, Wijkstra H et al. Hourglass-shaped nitinol prostatic stent in treatment of patients with lower urinary tract symptoms due to bladder outlet obstruction. Urology 2005; 66(4):845-9.
5. van Dijk MM, Mochtar CA, Wijkstra H et al. The bell-shaped nitinol prostatic stent in the treatment of lower urinary tract symptoms: experience in 108 patients. Eur Urol 2006; 49(2):353-9.i

6. Vanderbrink BA, Rastinehad AR, Badlani GH. Prostatic stents for the treatment of benign prostatic hyperplasia. Curr Opin Urol 2007; 17(1):1-6.ii

   This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.

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