Prostatic Urethral Lifts Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 12|01|2025 POLICY LAST REVIEWED: 09|03|2025 OVERVIEW Benign prostatic hyperplasia is a common condition in older men that can lead to increased urinary frequency, urgency, nocturia, hesitancy, and weak urinary stream. The prostatic urethral lift (PUL) procedure involves the insertion of 1 or more permanent implants into the prostate, which retract prostatic tissue and maintain an expanded urethral lumen.
MEDICAL CRITERIA Not applicable PRIOR AUTHORIZATION Not applicable POLICY STATEMENT Medicare Advantage Plans and Commercial Products Effective 12/1/2025, Prostatic Urethral Lift is covered for both Medicare Advantage Plans and Commercial Products COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage or Subscriber Agreement for applicable not medically necessary benefits/coverage. BACKGROUND Not applicable CODING Medicare Advantage Plans and Commercial Products Effective 12/1/2025, the following code(s) are covered for Medicare Advantage Plans and Commercial Products and do not require prior authorization:
52441 Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single implant
52442 Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; each additional permanent adjustable transprostatic implant (List separately in addition to code for primary procedure)
C9739 Cystourethroscopy, with insertion of transprostatic implant; 1 to 3 implants (for institutional providers use only) C9740 Cystourethroscopy, with insertion of transprostatic implant; 4 or more Implants (for institutional providers use only) RELATED POLICIES Not applicable PUBLISHED Provider Update, November 2025 Provider Update, November 2024 Provider Update, April 2023 Provider Update, November 2022 Provider Update, September 2021 Medical Coverage Policy | Prostatic Urethral Lifts

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

REFERENCES Not applicable

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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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