Prostate Procedures Form

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Prostate Procedures (BPH and Prostate Cancer) - Medical Policy
Updated Revision Effective: September 1, 2024 Policy Number:

UM987POL

Approval Date: 6/24/2025

Line(s) of Business:
Commercial
Medicare Advantage
Medicaid (BeHealthy)

Description

Benign Prostatic Hyperplasia (BPH)

BPH is a common disorder among older individuals that results from hyperplastic nodules in the periurethral or transitional zone of the prostate. The clinical manifestations of BPH include increased urinary frequency, nocturia, urgency or hesitancy to urinate, and a weak stream when urinating. The urinary tract symptoms often progress with worsening hypertrophy and may lead to acute urinary retention, incontinence, renal insufficiency, and/or urinary tract infection. Benign prostatic hyperplasia prevalence increases with age and is present in more than 80% of individuals ages 70 to 79 years.1,

Two scores are widely used to evaluate BPH-related symptoms: the American Urological Association Symptom Index (AUASI) and the International Prostate Symptom Score (IPSS). The AUASI is a self-administered 7-item questionnaire assessing the severity of various urinary symptoms.2, Total AUASI scores range from 0 to 35, with overall severity categorized as mild (≤7), moderate (8-19), or severe (20- 35).1, The IPSS incorporates questions from the AUASI and a quality-of-life question or a "Bother score."3,

Many treatment options are available to help manage moderate to severe lower urinary tract symptoms secondary to benign prostatic hyperplasia (BPH). In most cases, medication management is used as the initial course of therapy followed by transurethral resection of the prostate (TURP). TURP is considered the GOLD standard of care however; this is a surgical procedure requiring the use of anesthesia and is associated with longer recovery times and significant side effects. Some common side effects include heavy bleeding, urinary tract infections, and erectile dysfunction or retrograde ejaculation. TURP is not indicated for individuals who are contraindicated for general anesthesia or are desiring of preserving sexual function. Rates of retreatment are lower with TURP than other treatment modalities.

Less invasive treatment options such as the Prostatic Urethral Lift (PUL) and transurethral water vapor thermal therapy (Rezum) have been evaluated for the treatment of BPH. Prostatic urethral lift (PUL) involves the insertion of one or more permanent implants into the prostate, which retracts prostatic tissue and maintains an expanded urethral lumen. Rezum water vapor thermal therapy delivers a heated stream of water vaporizing prostate tissue

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and immediately reducing symptoms. Unlike other BPH treatments, Rezum allows for treatment of an obstructed median lobe, which may have additional impacts on LUTS. PUL and Rezum are indicated for men with moderate to severe LUTS with prostate sizes <80 cc and can be done in the outpatient setting without the use of general anesthesia. Both PUL and Rezum are safe options for men who have not responded adequately to medication therapy, are contraindicated to more invasive treatment options and are desiring of preserving sexual function.

Aquablation therapy has been evaluated for BPH and was recently approved by the FDA to treat enlarged prostates up to 150cc. Aquablation uses a heat free waterjet in conjunction with the AquaBeam robotic system to remove prostate tissue blocking the flow of urine. Aquablation therapy uses a cystoscope in combination with ultrasound imaging providing for direct visualization of the prostate. This provides for greater efficacy and treatment to areas of the prostate that will not result in further complications such as erectile dysfunction or incontinence. Aquablation is a surgical procedure-requiring anesthesia.

Laser therapies such as photoselective vaporization of the prostate (PVP), holmium laser ablation of the prostate (HoLAP) or Holmium Laser enucleation of the prostate (HoLEP) are options for individuals who may be taking blood thinners or are contraindicated to treatment options that may cause heavy bleeding. PVP and HoLAP use laser therapy to vaporize prostate tissue and allow for greater urinary flow. HoLEP is a laser-based procedure that excises prostate tissue blocking the urethra. Laser based procedures are effective for reducing prostate size and allowing for greater urinary flow while providing shorter recovery times, improvements in urinary symptoms and are not associated with increased risk of bleeding. Some of the adverse events or side effects of laser therapies include UTI, stricture of the urethra, erectile dysfunction, retrograde ejaculation, and need for retreatment.

Transurethral incision of the prostate (TUIP) is done by inserting small incisions into the prostate through the urethra allowing urine to pass through more freely. TUIP is indicated for small or moderate size prostates and is beneficial for patients who are contraindicated to medication management or other therapies. TUIP is a similarly effective procedure for reducing LUTS symptoms, providing a faster recovery period time, and lower incidences of erectile dysfunction and post op complications/bleeding. While TUIP is described as a viable alternative to TURP, the effectiveness of this procedure in larger prostates (>30) is not well documented.

Transurethral Microwave ablation (TUMT) is an outpatient treatment option for benign prostatic hyperplasia. TUMT has been evaluated as an effective option for men with smaller to medium size prostates who are not candidates for alternative treatments and who are suboptimal candidates for anesthesia. During TUMT, a microwave antenna is inserted into the urethra and delivers microwave thermal energy to the prostate to heat and destroy enlarged tissue. TUMT is known as a safer alternative with no requirement for anesthesia, lower risk of bleeding and low risk of long-term side effects. The rates of retreatment for TUMT are higher than those for TURP or other minimally invasive treatment options however, the low risk of side effects or complications makes this a beneficial treatment option for certain target populations.

Cryosurgical Ablation is the process of freezing tissue around the prostate during ultrasound or MRI ultrasound guidance. While often used to treat prostate cancer, cryosurgical ablation has been evaluated for the treatment of Benign Prostatic Hyperplasia. During the procedure, multiple metal probes are inserted around and under the prostate via ultrasound guidance and are then cooled sufficiently enough to freeze prostate tissue resulting in cell death and reduction of prostate gland size.

Prostatic Arterial Embolization is a minimally invasive treatment option that works by reducing blood supply to prostatic arteries. An interventional radiologist injects microspheres through a catheter to the blood vessels around the prostate, reducing the blood supply to multiple different areas. No surgical intervention is required for this procedure and recovery times are often less than that of TURP. PAE requires significant clinician training and is associated with some common side effects such as “post-PAE syndrome, blood in urine or semen, rare cases of prostatic or bladder spasms.

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Temporarily Implanted Nitinol Device (iTind) has been investigated as a minimally invasive treatment for lower urinary tract symptoms associated with BPH. With the use of a rigid cystoscope, the device is temporarily implanted into the obstructed prostatic urethra where three double intertwined nitinol struts configured in a tulip shape gradually expand. The resulting circumferential force facilitates tissue reshaping via ischemic necrosis of the mucosa, resulting in urethral expansion and prostatic incisions that function as longitudinal channels to improve urine outflow. The implant is typically removed after 5 to 7 days of treatment. A distal nylon wire facilitates device retrieval, which may be approached using a snare to pull the device into either a cystoscope sheath or an open-ended silicone catheter (20-22 Fr). The first generation TIND device had one extra strut and a pointed tip covered by a soft plastic material.

Transurethral needle ablation (TUNA) has been used to treat benign prostatic hyperplasia for many years. TUNA is done by inserting interstitial radiofrequency (RF) needles into the urethra and delivering radiofrequency ablation to the lateral lobes of the prostate. TUNA helped to reduce symptoms of LUTS due to BPH however, as newer, more effective treatment options became available TUNA has fallen out of favor. In some scenarios, patients who received TUNA had a new onset or worsening of symptoms due to chronic inflammation in the areas treated. TUNA has also been associated with high rates of retreatment and long-term side effects.

Prostate Cancer

Peri-prostatic, transperineal placement of biodegradable material (prostate rectal spacers, e.g. SpaceOAR, Barrigel) are various materials or devices placed between the prostate and anterior wall of the rectum for use in men receiving radiation therapy for prostate cancer. The anterior wall of the rectum is considered a major dose- limiting factor in radiation therapy of prostate cancer. Physical separation is proposed to allow reduced toxicity and treatment intensification. SpaceOAR is a biodegradable polyethylene glycol hydrogel that is injected as a liquid between the prostate and rectum under ultrasound guidance. Once injected, the liquid solidifies within seconds into a hydrogel that pushes the anterior rectal wall away from the prostate. The goal of this implantation is to separate the rectum from the prostate to decrease rectal exposure during radiation treatment for prostate cancer. SpaceOAR is completely resorbed by the body over time. Barrigel, an injectable gel, is an FDA-cleared hydrogel spacer that is used for separation of the prostate and rectum during radiotherapy. It is indicated to temporarily position the anterior wall of the rectum away from the prostate during radiotherapy for localized prostate cancer; and in creating this space, it is the intent of Barrigel to reduce the radiation dose delivered to the anterior rectum. Barrigel is composed of biodegradable hyaluronic acid and maintains space for the entire course of prostate radiotherapy treatment; and it is absorbed by the patient's body over time.

Brachytherapy is one of the several options for treating prostate cancer that has not spread to distant organs. It entails insertion of radioactive material into or near cancerous tissue or a tumor. Low-dose rate seeds are left in place permanently and give off radiation over several weeks to months. With high-dose rate seeds, the patient is treated temporarily, and the radioactive material is removed. Brachytherapy can be used alone or in combination with external beam radiation therapy or androgen deprivation therapy. Long-term outcome is dependent on tumor stage, Gleason score, and the dose of radiation to the targeted tissue.

 Line of Business

Commercial:

• HNE has adopted InterQual* criteria for the following procedures:

o Transurethral Water Vapor Thermal Therapy: CP: Procedures, Prostatectomy, Transurethral Ablation, Transurethral Destruction of Prostate Tissue, Water Vapor Thermal Therapy

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o Transurethral Microwave Thermotherapy (TUMT): CP: Procedures, Prostatectomy, Transurethral Ablation o Photoselective Vaporization of the Prostate (PVP): CP: Procedures, Prostatectomy, Transurethral Ablation o Transurethral Holmium Laser Ablation of the Prostate (HoLAP): CP: Procedures, Prostatectomy, Transurethral Ablation o Cryosurgery, Cryosurgical Ablation, Cryotherapy: CP: Procedures, Cryoablation, Prostate

• Refer to criteria under the Policy section in this medical policy for the following procedures:

o Prostatic Urethral Lift.
o Transurethral water jet ablation of the prostate. o Prostatic Artery Embolization for Benign Prostatic Hyperplasia. o Temporarily Implanted Nitinol Device for Benign Prostatic Hyperplasia (iTind) o Transurethral Needle Ablation (TUNA)
o Transperineal laser ablation (TPLA) o Transurethral balloon dilatation for treatment of BPH (e.g. Optilume Basic or drug-coated balloon). o Urethral therapeutic drug delivery by drug-coated balloon catheter for urethral stricture or stenosis in males (Optilume). o High Intensity Focused Ultrasound (HIFU) o Peri-prostatic, transperineal placement of biodegradable material. o Experimental/Investigational ablative procedures.

Medicaid – BeHealthy:

• HNE has adopted InterQual* criteria for the following procedures:

o Transurethral Water Vapor Thermal Therapy: CP: Procedures, Prostatectomy, Transurethral Ablation, Transurethral Destruction of Prostate Tissue, Water Vapor Thermal Therapy o Transurethral Microwave Thermotherapy (TUMT): CP: Procedures, Prostatectomy, Transurethral Ablation o Photoselective Vaporization of the Prostate (PVP): CP: Procedures, Prostatectomy, Transurethral Ablation o Transurethral Holmium Laser Ablation of the Prostate (HoLAP): CP: Procedures, Prostatectomy, Transurethral Ablation o Cryosurgery, Cryosurgical Ablation, Cryotherapy: CP: Procedures, Cryoablation, Prostate

• Refer to criteria under the Policy section in this medical policy for the following procedures:

o Prostatic Urethral Lift.
o Transurethral water jet ablation of the prostate. o Prostatic Artery Embolization for Benign Prostatic Hyperplasia. o Temporarily Implanted Nitinol Device for Benign Prostatic Hyperplasia (iTind). o Transurethral Needle Ablation (TUNA). o Transperineal laser ablation (TPLA). o Transurethral balloon dilatation for treatment of BPH (e.g. Optilume Basic or drug-coated balloon). o Urethral therapeutic drug delivery by drug-coated balloon catheter for urethral stricture or stenosis in males (Optilume).

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o High Intensity Focused Ultrasound (HIFU) o Peri-prostatic, transperineal placement of biodegradable material. o Experimental/Investigational ablative procedures.

• There are no MassHealth guidelines for any Prostate Procedures for either BPH or Prostate Cancer.

Medicare:

• HNE has adopted InterQual* criteria for the following procedures:

o Transurethral Water Vapor Thermal Therapy: CP: Procedures, Prostatectomy, Transurethral Ablation, Transurethral Destruction of Prostate Tissue, Water Vapor Thermal Therapy o Transurethral Microwave Thermotherapy (TUMT): CP: Procedures, Prostatectomy, Transurethral Ablation o Photoselective Vaporization of the Prostate (PVP): CP: Procedures, Prostatectomy, Transurethral Ablation o Transurethral Holmium Laser Ablation of the Prostate (HoLAP): CP: Procedures, Prostatectomy, Transurethral Ablation

• Refer to criteria under the Policy section in this medical policy for the following procedures:

o Prostatic urethral lift. o Transurethral microwave therapy. o Temporarily Implanted Nitinol Device for Benign Prostatic Hyperplasia (iTind). o Transurethral Needle Ablation (TUNA). o Transperineal laser ablation (TPLA). o Transurethral balloon dilatation for treatment of BPH (e.g. Optilume Basic or drug-coated balloon). o Urethral therapeutic drug delivery by drug-coated balloon catheter for urethral stricture or stenosis in males (Optilume). o High intensity focused ultrasound (HIFU). o Peri-prostatic, transperineal placement of biodegradable material. o Experimental/Investigational ablative procedures.

• Medicare does not have a National Coverage Determination (NCD) criteria or a Local Coverage Determination (LCD) for the above procedures.

• The following National Coverage Determination (NCD) or Local Coverage Determination (LCD) can be found at MCD Search (cms.gov):

o Transurethral water jet ablation of the prostate: LCD L38367, Fluid Jet System Treatment for LUTS/BPH. o Cryosurgical ablation: NCD 230.9, Cryosurgery of Prostate

*To obtain InterQual® SmartSheets™: If you are a registered Health New England provider click here: https://www.hnedirect.com/login/ to access the Provider website. If you do not have access to the portal call (413) 787-4004 to obtain a copy.

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Policy

Procedures for Benign prostatic hyperplasia

I. High-energy water vapor thermotherapy

A. Health New England has adopted following InterQual criteria:

• CP: Procedures, Prostatectomy, Transurethral Ablation

B. High-energy water vapor thermotherapy for the treatment of malignant prostate tissue or all other indications other than in criteria above is considered NOT MEDICALLY NECESSARY.

II. Transurethral Microwave Therapy (TUMT)

A. Health New England has adopted following InterQual criteria:

• CP: Procedures, Prostatectomy, Transurethral Ablation

B. Transurethral microwave therapy (TUMT) for all other indications other than in criteria above is considered NOT MEDICALLY NECESSARY.

III. Prostatic Urethral Lift (PUL)

A. Prostatic Urethral Lift may be considered MEDICALLY NECESSARY for patients with a diagnosis of moderate-to-severe lower urinary tract obstruction due to benign prostatic hyperplasia, who meet ALL of the following:

1. Age 45 years of age or older; AND
2. Estimated prostate volume <= 80 cc by radiologic studies, or by digital rectal exam and/or cystoscopy if obvious or if radiology studies are not possible (may be confirmed with transrectal ultrasound); AND
3. Prostate anatomy demonstrates normal bladder neck without an obstructive median lobe: AND
4. Contraindication to, intolerance of, or failure of at least three months of standard medical therapy for BPH – (i.e. alpha blocker, finasteride/dutasteride, PDE5 inhibitor); AND
5. A diagnosis of urinary obstruction either by a clear clinical history, cystoscopy, urodynamics, or a peak urine flow rate (Qmax) less than 15 cc/sec on a voided volume that is greater than 125 cc; AND

6. IF a prostate specific antigen (PSA) is indicated in an individual with a diagnosis of LUTS and BPH with the PSA level meeting the following criteria:
   i. Taken within 12 months of the procedure; AND
   ii. Resulted in a value of 4.0 ng/mL or less, or age adjusted level; OR
   iii. Has had at least one negative biopsy if the PSA is elevated for age.

   B. Prostatic urethral lift (PUL) for all other indications other than in criteria above for benign prostatic hyperplastic is considered NOT MEDICALLY NECESSARY.

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IV. Transurethral water jet ablation of the prostate

A. Transurethral water jet ablation of the prostate (e.g., AquaBeam System) in patients 45 and older may be considered MEDICALLY NECESSARY for the treatment of moderate to severe lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia as an alternative to transurethral resection of the prostate (TURP) or open prostatectomy when ALL of the following criteria are met.

1. The Individual has persistent or progressive lower urinary tract symptoms despite medical therapy (α1-adrenergic antagonists maximally titrated, 5α-reductase inhibitors, or combination medication therapy maximally titrated) over a trial period of no less than 6 months OR is unable to tolerate medical therapy OR the patient is not a suitable candidate for anesthesia; AND
2. IPSS score ≥12, AND
3. Prostate gland volume ≥30 – 150cc; AND
4. Individual does not have an active urinary tract infection or prostatitis within the past year; AND
5. Individual does not have diagnosis of urethral stricture, meatal stenosis, or bladder neck contracture, AND
6. Individual does not have a known allergy to nickel, titanium or stainless steel, AND

7. Individual has had appropriate testing to exclude diagnosis of prostate cancer.

   B. Health New England has adopted LCD L38367, Fluid Jet System Treatment for LUTS/BPH, for Transurethral water jet ablation of the prostate.

   C. Transurethral water jet ablation of the prostate for all other indications other than in criteria above is considered NOT MEDICALLY NECESSARY.

   V. Cryosurgical Ablation and Prostatic Artery Embolization for Benign Prostatic Hyperplasia

   • Considered EXPERIMENTAL and INVESTIGATIONAL due to insufficient evidence of safety and/or efficacy.

   VI. Temporarily Implanted Nitinol Device for Benign Prostatic Hyperplasia (iTind)

   • Considered EXPERIMENTAL and INVESTIGATIONAL due to insufficient evidence of safety and/or efficacy.

   VII. Transurethral Needle Ablation (TUNA)

   • Considered EXPERIMENTAL and INVESTIGATIONAL due to insufficient evidence of safety and/or efficacy.

   VIII. Transperineal laser ablation (TPLA)

   • Considered EXPERIMENTAL and INVESTIGATIONAL due to insufficient evidence of safety and/or efficacy.

   IX. Transurethral balloon dilatation for treatment of BPH (e.g. Optilume Basic or drug-coated balloon)

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• Considered EXPERIMENTAL and INVESTIGATIONAL due to insufficient evidence of safety and/or efficacy.

X. Urethral therapeutic drug delivery by drug-coated balloon catheter for urethral stricture or stenosis in males (Optilume)

• Considered EXPERIMENTAL and INVESTIGATIONAL due to insufficient evidence of safety and/or efficacy.

• Urethral dilation or direct visual internal urethrotomy, combined with drug-coated balloons may be considered MEDICALLY NECESSARY for recurrent bulbar urethral strictures <3cm in length.

Procedures for Prostate Cancer

I. Cryoablation

A. Health New England has adopted the following InterQual criteria:

• CP: Procedures, Cryoablation, Prostate

B. Health New England has adopted NCD 230.9 for Cryosurgical ablation.

C. Cryoablation of the prostate for initial treatment of prostate cancer and for all other indications other than in criteria above is considered NOT MEDICALLY NECESSARY.

II. High Intensity Focused Ultrasound (HIFU)

• Considered EXPERIMENTAL and INVESTIGATIONAL due to insufficient evidence of safety and/or efficacy.

III. Peri-prostatic, transperineal placement of biodegradable material

A. The transperineal placement of biodegradable material, peri-prostatic (via needle) is proven and medically necessary for reducing rectal toxicity in men undergoing radiotherapy for prostate cancer.

B. The transperineal placement of biodegradable material, peri-prostatic (via needle) for all other indications other than in criteria above is considered NOT MEDICALLY NECESSARY.

IV. Prostatic Urethral Lift (PUL)

A. Prostatic Urethral Lift may be considered MEDICALLY NECESSARY for patients with a diagnosis of moderate-to-severe lower urinary tract obstruction with a history of/or current prostate cancer when ONE of the following criteria are met:

1. The individual is not a candidate for surgical resection of the prostate but will be treated by radiation therapy and has symptoms that are so severe that immediate relief is required; OR
2. The individual is clinically in remission OR the individual is on active surveillance for low or very low risk prostate cancer AND satisfies ALL of the following:

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a. Estimated prostate volume <= 80 cc by radiologic studies, or by digital rectal exam and/or cystoscopy if obvious or if radiology studies are not possible (may be confirmed with transrectal ultrasound); AND
b. Prostate anatomy demonstrates normal bladder neck without an obstructive median lobe: AND
c. A diagnosis of urinary obstruction either by a clear clinical history, cystoscopy, urodynamics, or a peak urine flow rate (Qmax) less than 15 cc/sec on a voided volume that is greater than 125 cc.

B. Prostatic urethral lift (PUL) for all other indications other than in criteria above prostate cancer is considered NOT MEDICALLY NECESSARY

V. Experimental/Investigational ablative procedures.

A. Following ablative procedures are considered EXPERIMENTAL and INVESTIGATIONAL for the treatment (primary or salvage therapy) of prostate cancer because their effectiveness has not been established (not an all-inclusive list):

a. Focal thermo-ablative therapy for the treatment of oligometastatic prostate cancer (OMPC)
b. Dual-fiber laser ablation c. Irreversible electroporation therapy
d. Magnetic field induction ablation
e. Magnetic resonance imaging (MRI)-guided focal laser ablation (e.g., the Visualase Laser Ablation System)
f. Transperineal focal laser ablation (Tranberg Thermal Therapy System)
g. MRI-guided transurethral ultrasound ablation
h. Photothermal ablation with copper sulfide nanoplates
i. Vascular targeted photodynamic therapy (also known as soluble focal therapy) j. Water vapor thermotherapy (for prostate cancer)

Coding Guidance

Code
Description
Policy instructions CPT

0421T Transurethral waterjet ablation of prostate, including control of post- operative bleeding, including ultrasound guidance, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when performed) PA Required 0582T Transurethral ablation of malignant prostate tissue by high-energy water vapor thermotherapy, including intraoperative imaging and needle guidance Experimental/ Investigational 0600T Ablation, irreversible electroporation; 1 or more tumors per organ, including imaging guidance, when performed, percutaneous Experimental/ Investigational 0655T Transperineal focal laser ablation of malignant prostate tissue, including transrectal imaging guidance, with MR-fused images or other enhanced ultrasound imaging Experimental/ Investigational 0714T Transperineal laser ablation of benign prostatic hyperplasia, including imaging guidance Experimental/ Investigational

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Code
Description
Policy instructions 0738T Treatment planning for magnetic field induction ablation of malignant prostate tissue, using data from previously performed magnetic resonance imaging (MRI) examination Experimental/ Investigational 0739T Ablation of malignant prostate tissue by magnetic field induction, including all intraprocedural, transperineal needle/catheter placement for nanoparticle installation and intraprocedural temperature monitoring, thermal dosimetry, bladder irrigation, and magnetic field nanoparticle activation Experimental/ Investigational 0950T Ablation of benign prostate tissue, transrectal, with high intensity- focused ultrasound (HIFU), including ultrasound guidance Experimental/ Investigational 37242 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; arterial, other than hemorrhage or tumor (eg, congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms) Experimental/ Investigational when used for treatment of BPH 52282 Cystourethroscopy, with insertion of permanent urethral stent NO PA 52284 Cystourethroscopy, with mechanical urethral dilation and urethral therapeutic drug delivery by drug-coated balloon catheter for urethral stricture or stenosis, male, including fluoroscopy, when performed Experimental/ Investigational 52441 Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single implant PA Required 52442 Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; each additional permanent adjustable transprostatic implant (List separately in addition to code for primary procedure) PA Required 52450 Transurethral incision of prostate NO PA 52601 Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included) NO PA 52647
Laser coagulation of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included if performed) NO PA 52648
Laser vaporization of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, internal urethrotomy and transurethral resection of prostate are included if performed) NO PA 52649 Laser enucleation of the prostate with morcellation, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, internal urethrotomy and transurethral resection of prostate are included if performed) NO PA 53850 Transurethral destruction of prostate tissue; by microwave thermotherapy PA Required 53852 Transurethral destruction of prostate tissue; by radiofrequency thermotherapy Experimental/ Investigational

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Code
Description
Policy instructions 53854 Transurethral destruction of prostate tissue; by radiofrequency generated water vapor thermotherapy PA Required 53855 Insertion of a temporary prostatic urethral stent, including urethral measurement Experimental/ Investigational 53899 Unlisted procedure, urinary system Not covered when used to describe a procedure listed as Experimental/ Investigational 55831 Prostatectomy (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy); retropubic, subtotal No PA 55840 Prostatectomy, retropubic radical, with or without nerve sparing No PA 55842 Prostatectomy, retropubic radical, with or without nerve sparing; with lymph node biopsy(s) (limited pelvic lymphadenectomy) No PA 55845 Prostatectomy, retropubic radical, with or without nerve sparing; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes No PA 55866 Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed No PA 55873 Cryosurgical ablation of the prostate (includes ultrasonic guidance and monitoring)

PA Required Experimental/ Investigational when used for the treatment of BPH 55874 Transperineal placement of biodegradable material, peri-prostatic, single or multiple injection(s), including image guidance, when performed PA Required 55875 Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy No PA 55876 Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), prostate (via needle, any approach), single or multiple No PA 55880 Ablation of malignant prostate tissue, transrectal, with high intensity- focused ultrasound (HIFU), including ultrasound guidance Experimental/ Investational 55899 Unlisted procedure, male genital system Not covered when used to describe a procedure listed as Experimental/ Investigational 77770 Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 1 channel
No PA

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Code
Description
Policy instructions 77771 Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 2-12 channels No PA 77772 Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; over 12 channels No PA 77778 Interstitial radiation source application, complex, includes supervision, handling, loading of radiation source, when performed No PA C9734 Focused ultrasound ablation/therapeutic intervention, other than uterine leiomyomata, with magnetic resonance (mr) guidance Experimental/ Investigational CPT® Copyright 2025 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Note: CPT/HCPCS codes are included for informational purposes and may not be all inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

References

Benign Prostatic Hyperplasia

1. McVary, K.T., Gittelman, M.C., Goldberg, K.A., et al. Final 5-Year Outcomes of the Multicenter Randomized Sham-Controlled Trial of Rezūm Water Vapor Thermal Therapy for Treatment of Moderate-to-Severe Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia, The Journal of Urology® (2021), doi: 10.1097/JU.0000000000001778.

2. McVary KT, Roehrborn CG, Avins AL, et al. American Urological Association Guideline: Management of Benign Prostatic Hyperplasia (BPH). 2010 (affirmed 2014);

3. Roehrborn CG, Gange SN, Shore ND, et al. The prostatic urethral lift for the treatment of lower urinary tract symptoms associated with prostate enlargement due to benign prostatic hyperplasia: the L.I.F.T. Study. J Urol. Dec 2013; 190(6): 2161-7. PMID 23764081

4. McVary KT, Gange SN, Shore ND, et al. Treatment of LUTS secondary to BPH while preserving sexual function: randomized controlled study of prostatic urethral lift. J Sex Med. Jan 2014; 11(1): 279-87. PMID 24119101

5. Shore N. A Review of the Prostatic Urethral Lift for Lower Urinary Tract Symptoms: Symptom Relief, Flow Improvement, and Preservation of Sexual Function in Men With Benign Prostatic Hyperplasia. Curr Bladder Dysfunct Rep. NA 2015; 10(2): 186-192. PMID 25984251

6. Roehrborn CG, Rukstalis DB, Barkin J, et al. Three year results of the prostatic urethral L.I.F.T. study. Can J Urol. Jun 2015; 22(3): 7772-82. PMID 26068624

7. Rukstalis D, Rashid P, Bogache WK, et al. 24-month durability after crossover to the prostatic urethral lift from randomised, blinded sham. BJU Int. Oct 2016; 118 Suppl 3: 14-22. PMID 27684483

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8. Gratzke C, Barber N, Speakman MJ, et al. Prostatic urethral lift vs transurethral resection of the prostate: 2- year results of the BPH6 prospective, multicentre, randomized study. BJU Int. May 2017; 119(5): 767-775. PMID 27862831

9. Miller LE, Chughtai B, Dornbier RA, et al. Surgical Reintervention Rate after Prostatic Urethral Lift: Systematic Review and Meta-Analysis Involving over 2,000 Patients. J Urol. May 12 2020: 101097JU0000000000001132. PMID 32396049

10. Roehrborn CG, Barkin J, Gange SN, et al. Five year results of the prospective randomized controlled prostatic urethral L.I.F.T. study. Can J Urol. Jun 2017; 24(3): 8802-8813. PMID 28646935

11. Eure G, Gange S, Walter P, et al. Real-World Evidence of Prostatic Urethral Lift Confirms Pivotal Clinical Study Results: 2-Year Outcomes of a Retrospective Multicenter Study. J Endourol. Jul 2019; 33(7): 576-584. PMID 31115257

12. National Institute for Health and Care Excellence (NICE). Insertion of prostatic urethral lift implants to treat lower urinary tract symptoms secondary to benign prostatic hyperplasia [IPG475]. 2014; https://www.nice.org.uk/guidance/ipg475/chapter/1-recommendations. Accessed July 2, 2020.

13. National Institute for Health and Care Excellence (NICE). UroLift for treating lower urinary tract symptoms of benign prostatic hyperplasia [MTG26]. 2015; https://www.nice.org.uk/guidance/mtg26. Accessed July 2, 2020.

14. Abt D, Hechelhammer L, Müllhaupt G et al. Comparison of prostatic artery embolisation (PAE) versus transurethral resection of the prostate (TURP) for benign prostatic hyperplasia: randomised, open label, non- inferiority trial. BMJ. 2018; 361; k23338.

15. Barry MJ, Fowler FJ Jr, O'leary MP et al. Measurement Committee of the American Urological Association. The American Urological Association Symptom Index for Benign Prostatic Hyperplasia. J Urol. 2017; 197(2S):S189-S197.

16. Bouza C, Lopez T, Magro A, et al. Systematic review and meta-analysis of transurethral needle ablation in symptomatic benign prostatic hyperplasia. BMC Urol. 2006; 6:14.

17. Cimentepe E, Unsal A, Saglam R. Randomized clinical trial comparing transurethral needle ablation with transurethral resection of the prostate for the treatment of benign prostatic hyperplasia: results at 18 months. J Endourol. 2003; 17(2):103-7.

18. Foster HE, Barry, MJ, Dahm P et al. Surgical management of lower urinary tract symptoms attributed to benign prostatic hyperplasia: AUA guideline. Available at: https://www.auanet.org/guidelines/benign-prostatic- hyperplasia-(bph)-guideline. Accessed on January 15, 2020.

19. Riehmann M, Knes JM, Heisey D, et al. Transurethral resection versus incision of the prostate: a randomized, prospective study. Urology. 1995; 45(5):768-775.

20. Gilling, P., Barber, N., Bidair, M., et al. WATER: A double blind, randomized, controlled trial of Aquablation vs transurethral resection of the prostate in benign prostatic hyperplasia. J Urol. May 2018. 199(5). 1252-1261.

21. Insasti, I., Saez de Ocariz, A., Galbete, A., et al. Randomized Comparison of Prostatic Artery Embolization versus resection of the prostate for treatment of bengin prostatic hyperplasia. J Vasc Interv Radiol. June 2020. 31(6). 882-890.

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22. McVary, K.T., Gange, S.N., Gittelman, M.C., et al. Minimally invasive prostate convection water vapor energy ablation: A Multicenter, Randomized, Controlled Study for the Treatment of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia. J Urol. May 2016. 195(5). 1529-1538.

23. Mordasini, L., Di Bona, C., Klein, J., et al. 80-W GreenLight Laser Vaporization Versus Transurethral Resection of the Prostate for the Treatment of Benign Prostatic Obstruction: 5-year outcomes from a Single-center Prospective Randomized Trial. Urology. June 2018. 116. 144-140.

24. Zhang, J., Ou, Z., Zhang, X., et al. Holmium Laser Enucleation of the Prostate Versus thulium laser enucleation of the prostate for the treatment of large-volume prostates >80ml: 18 month follow up results. World J. Urol. June 2020. 38(6). 1555-1562.

25. Balakrishnan D, Jones P, Somani BK. iTIND: the second-generation temporary implantable nitinol device for minimally invasive treatment of benign prostatic hyperplasia. Ther Adv Urol. 2020; 12: 1756287220934355. PMID 32655690

26. Porpiglia F, Fiori C, Bertolo R, et al. Temporary implantable nitinol device (TIND): a novel, minimally invasive treatment for relief of lower urinary tract symptoms (LUTS) related to benign prostatic hyperplasia (BPH): feasibility, safety and functional results at 1 year of follow-up. BJU Int. Aug 2015; 116(2): 278-87. PMID 25382816

27. Porpiglia F, Fiori C, Bertolo R, et al. 3-Year follow-up of temporary implantable nitinol device implantation for the treatment of benign prostatic obstruction. BJU Int. Jul 2018; 122(1): 106-112. PMID 29359881

28. Franco JV, Jung JH, Imamura M, et al. Minimally invasive treatments for lower urinary tract symptoms in men with benign prostatic hyperplasia: a network meta-analysis. Cochrane Database Syst Rev. Jul 15 2021; 7(7): CD013656. PMID 34693990

29. Chughtai B, Elterman D, Shore N, et al. The iTind Temporarily Implanted Nitinol Device for the Treatment of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia: A Multicenter, Randomized, Controlled Trial. Urology. Jul 2021; 153: 270-276. PMID 33373708

30. Porpiglia F, Fiori C, Amparore D, et al. Second-generation of temporary implantable nitinol device for the relief of lower urinary tract symptoms due to benign prostatic hyperplasia: results of a prospective, multicentre study at 1 year of follow-up. BJU Int. Jun 2019; 123(6): 1061-1069. PMID 30382600

31. Kadner G, Valerio M, Giannakis I, et al. Second generation of temporary implantable nitinol device (iTind) in men with LUTS: 2-year results of the MT-02-study. World J Urol. Dec 2020; 38(12): 3235- 3244. PMID 32124019

32. Amparore D, Fiori C, Valerio M, et al. 3-Year results following treatment with the second generation of the temporary implantable nitinol device in men with LUTS secondary to benign prostatic obstruction. Prostate Cancer Prostatic Dis. Jun 2021; 24(2): 349-357. PMID 33005003

33. De Nunzio C, Cantiello F, Fiori C, et al. Urinary and sexual function after treatment with temporary implantable nitinol device (iTind) in men with LUTS: 6-month interim results of the MT-06-study. World J Urol. Jun 2021; 39(6): 2037-2042. PMID 32851439

34. National Institute for Health and Care Excellence (NICE). Interventional procedures guidance: prostatic urethral temporary implant insertion for lower urinary tract symptoms caused by benign prostatic hyperplasia [IPG737]. September 21, 2022; https://www.nice.org.uk/guidance/ipg737. Accessed November 15, 2022.

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Prostatic Urethral Lift

1. Sarma AV, Wei JT. Clinical practice. Benign prostatic hyperplasia and lower urinary tract symptoms. N Engl J Med. Jul 19, 2012; 367(3): 248-57. PMID 22808960

2. Barry MJ, Fowler FJ, O'Leary MP, et al. Measuring disease-specific health status in men with benign prostatic hyperplasia. Measurement Committee of The American Urological Association. Med Care. Apr 1995; 33(4 Suppl): AS145-55. PMID 7536866

3. O'leary MP. Validity of the "bother score" in the evaluation and treatment of symptomatic benign prostatic hyperplasia. Rev Urol. 2005; 7(1): 1-10. PMID 16985801

4. Djavan B, Marberger M. A meta-analysis on the efficacy and tolerability of alpha1-adrenoceptor antagonists in patients with lower urinary tract symptoms suggestive of benign prostatic obstruction. Eur Urol. 1999; 36(1): 1-

5. PMID 10364649

6. Foster HE, Barry MJ, Dahm P, et al. Surgical Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA Guideline. J Urol. Sep 2018; 200(3): 612-619. PMID 29775639

7. Reich O, Gratzke C, Bachmann A, et al. Morbidity, mortality and early outcome of transurethral resection of the prostate: a prospective multicenter evaluation of 10,654 patients. J Urol. Jul 2008; 180(1): 246-9. PMID 18499179

8. Lerner LB, McVary KT, Barry MJ, et al. Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA GUIDELINE PART II-Surgical Evaluation and Treatment. J Urol. Oct 2021; 206(4): 818-

9. PMID 34384236

10. Sundaram D, Sankaran PK, Raghunath G, et al. Correlation of Prostate Gland Size and Uroflowmetry in Patients with Lower Urinary Tract Symptoms. J Clin Diagn Res. May 2017; 11(5): AC01-AC04. PMID 28658743

11. Rosen RC, Catania JA, Althof SE, et al. Development and validation of four-item version of Male Sexual Health Questionnaire to assess ejaculatory dysfunction. Urology. May 2007; 69(5): 805-9. PMID 17482908

12. Cappelleri JC, Rosen RC. The Sexual Health Inventory for Men (SHIM): a 5-year review of research and clinical experience. Int J Impot Res. Jul-Aug 2005; 17(4): 307-19. PMID 15875061

13. Sonksen J, Barber NJ, Speakman MJ, et al. Prospective, randomized, multinational study of prostatic urethral lift versus transurethral resection of the prostate: 12-month results from the BPH6 study. Eur Urol. Oct 2015; 68(4): 643-52. PMID 25937539

14. Barry MJ, Williford WO, Chang Y, et al. Benign prostatic hyperplasia specific health status measures in clinical research: how much change in the American Urological Association symptom index and the benign prostatic hyperplasia impact index is perceptible to patients?. J Urol. Nov 1995; 154(5): 1770- 4. PMID 7563343

15. Roehrborn CG, Wilson TH, Black LK. Quantifying the contribution of symptom improvement to satisfaction of men with moderate to severe benign prostatic hyperplasia: 4-year data from the CombAT trial. J Urol. May 2012; 187(5): 1732-8. PMID 22425127

16. McVary KT, Roehrborn CG, Avins AL, et al. American Urological Association Guideline: Management of Benign Prostatic Hyperplasia (BPH). 2010 (affirmed 2014); http://www.auanet.org/guidelines/benign-prostatic- hyperplasia-(2010-reviewed-and-validityconfirmed-2014). Accessed July 7, 2022.

16

15. Perera M, Roberts MJ, Doi SA, et al. Prostatic urethral lift improves urinary symptoms and flow while preserving sexual function for men with benign prostatic hyperplasia: a systematic review and metaanalysis. Eur Urol. Apr 2015; 67(4): 704-13. PMID 25466940

16. Cantwell AL, Bogache WK, Richardson SF, et al. Multicentre prospective crossover study of the 'prostatic urethral lift' for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia. BJU Int. Apr 2014; 113(4): 615-22. PMID 24765680

17. Shore N, Freedman S, Gange S, et al. Prospective multi-center study elucidating patient experience after prostatic urethral lift. Can J Urol. Feb 2014; 21(1): 7094-101. PMID 24529008

18. McNicholas TA, Woo HH, Chin PT, et al. Minimally invasive prostatic urethral lift: surgical technique and multinational experience. Eur Urol. Aug 2013; 64(2): 292-9. PMID 23357348

19. Chin PT, Bolton DM, Jack G, et al. Prostatic urethral lift: two-year results after treatment for lower urinary tract symptoms secondary to benign prostatic hyperplasia. Urology. Jan 2012; 79(1): 5-11. PMID 22202539

20. Woo HH, Bolton DM, Laborde E, et al. Preservation of sexual function with the prostatic urethral lift: a novel treatment for lower urinary tract symptoms secondary to benign prostatic hyperplasia. J Sex Med. Feb 2012; 9(2): 568-75. PMID 22172161

21. Woo HH, Chin PT, McNicholas TA, et al. Safety and feasibility of the prostatic urethral lift: a novel, minimally invasive treatment for lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). BJU Int. Jul 2011; 108(1): 82-8. PMID 21554526

22. Hoffman RM, Monga M, Elliott SP, et al. Microwave thermotherapy for benign prostatic hyperplasia. Cochrane Database Syst Rev. Sep 12, 2012; (9): CD004135. PMID 22972068

23. Roehrborn CG, Gange SN, Shore ND, et al. The prostatic urethral lift for the treatment of lower urinary tract symptoms associated with prostate enlargement due to benign prostatic hyperplasia: the L.I.F.T. Study. J Urol. Dec 2013; 190(6): 2161-7. PMID 23764081

24. Shore N. A Review of the Prostatic Urethral Lift for Lower Urinary Tract Symptoms: Symptom Relief, Flow Improvement, and Preservation of Sexual Function in Men With Benign Prostatic Hyperplasia. Curr Bladder Dysfunct Rep. NA 2015; 10(2): 186-192. PMID 25984251

25. Roehrborn CG, Rukstalis DB, Barkin J, et al. Three year results of the prostatic urethral L.I.F.T. study. Can J Urol. Jun 2015; 22(3): 7772-82. PMID 26068624

26. McVary KT, Gange SN, Shore ND, et al. Treatment of LUTS secondary to BPH while preserving sexual function: randomized controlled study of prostatic urethral lift. J Sex Med. Jan 2014; 11(1): 279-87. PMID 24119101

27. Garrido Abad P, Coloma Del Peso A, Sinues Ojas B, et al. [Urolift(R), a new minimally invasive treatment for patients with low urinary tract symptoms secondary to BPH. Preliminary results]. Arch Esp Urol. Jul-Aug 2013; 66(6): 584-91. PMID 23985459

28. Jones P, Rajkumar GN, Rai BP, et al. Medium-term Outcomes of Urolift (Minimum 12 Months Followup): Evidence From a Systematic Review. Urology. Nov 2016; 97: 20-24. PMID 27208817

17

29. Bozkurt A, Karabakan M, Keskin E, et al. Prostatic Urethral Lift: A New Minimally Invasive Treatment for Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia. Urol Int. 2016; 96(2): 202-6. PMID 26613256

30. Ray A, Morgan H, Wilkes A, et al. The Urolift System for the Treatment of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia: A NICE Medical Technology Guidance. Appl Health Econ Health Policy. Oct 2016; 14(5): 515-26. PMID 26832146

31. Tanneru K, Gautam S, Norez D, et al. Meta-analysis and systematic review of intermediate-term follow-up of prostatic urethral lift for benign prostatic hyperplasia. Int Urol Nephrol. Jun 2020; 52(6): 999-1008. PMID 32065331

32. Rukstalis D, Rashid P, Bogache WK, et al. 24-month durability after crossover to the prostatic urethral lift from randomised, blinded sham. BJU Int. Oct 2016; 118 Suppl 3: 14-22. PMID 27684483

33. Sievert KD, Schonthaler M, Berges R, et al. Minimally invasive prostatic urethral lift (PUL) efficacious in TURP candidates: a multicenter German evaluation after 2 years. World J Urol. Jul 2019; 37(7): 1353-1360. PMID 30283994

34. Jung JH, Reddy B, McCutcheon KA, et al. Prostatic urethral lift for the treatment of lower urinary tract symptoms in men with benign prostatic hyperplasia. Cochrane Database Syst Rev. May 25 2019; 5: CD012832. PMID 31128077

35. Gratzke C, Barber N, Speakman MJ, et al. Prostatic urethral lift vs transurethral resection of the prostate: 2- year results of the BPH6 prospective, multicentre, randomized study. BJU Int. May 2017; 119(5): 767-775. PMID 27862831

36. Franco JVA, Jung JH, Imamura M, et al. Minimally invasive treatments for benign prostatic hyperplasia: a Cochrane network meta-analysis. BJU Int. Aug 2022; 130(2): 142-156. PMID 34820997

37. Roehrborn CG. Prostatic Urethral Lift: A Unique Minimally Invasive Surgical Treatment of Male Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia. Urol Clin North Am. Aug 2016; 43(3): 357-69. PMID 27476128

38. Roehrborn CG, Barkin J, Gange SN, et al. Five year results of the prospective randomized controlled prostatic urethral L.I.F.T. study. Can J Urol. Jun 2017; 24(3): 8802-8813. PMID 28646935

39. Rukstalis D, Grier D, Stroup SP, et al. Prostatic Urethral Lift (PUL) for obstructive median lobes: 12-month results of the MedLift Study. Prostate Cancer Prostatic Dis. Sep 2019; 22(3): 411-419. PMID 30542055

40. Shah BB, Tayon K, Madiraju S, et al. Prostatic Urethral Lift: Does Size Matter?. J Endourol. Jul 2018; 32(7): 635-638. PMID 29631445

41. Eure G, Gange S, Walter P, et al. Real-World Evidence of Prostatic Urethral Lift Confirms Pivotal Clinical Study Results: 2-Year Outcomes of a Retrospective Multicenter Study. J Endourol. Jul 2019; 33(7): 576-584. PMID 31115257

42. Kaplan SA. Surgical Reintervention Rate after Prostatic Urethral Lift: Systematic Review and MetaAnalysis Involving over 2,000 Patients. Letter. J Urol. Mar 2021; 205(3): 939-940. PMID 33393811

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43. Miller LE, Chughtai B, Dornbier RA, et al. Surgical Reintervention Rate after Prostatic Urethral Lift: Systematic Review and Meta-Analysis Involving over 2,000 Patients. Reply. J Urol. Mar 2021; 205(3): 940-941. PMID 33393812

44. McVary KT, Kaplan SA. A Tower of Babel in Today's Urology: Disagreement in Concepts and Definitions of Lower Urinary Tract Symptoms/Benign Prostatic Hyperplasia Re-Treatment. J Urol. Aug 2020; 204(2): 213-214. PMID 32469261

45. Miller LE, Chughtai B, Dornbier RA, et al. Surgical Reintervention Rate after Prostatic Urethral Lift: Systematic Review and Meta-Analysis Involving over 2,000 Patients. J Urol. Nov 2020; 204(5): 1019- 1026. PMID 32396049

46. Gaffney CD, Basourakos SP, Al Hussein Al Awamlh B, et al. Adoption, Safety, and Retreatment Rates of Prostatic Urethral Lift for Benign Prostatic Enlargement. J Urol. Aug 2021; 206(2): 409-415. PMID 33793296 47. Page T, Veeratterapillay R, Keltie K, et al. Prostatic urethral lift (UroLift): a real-world analysis of outcomes using hospital episodes statistics. BMC Urol. Apr 07 2021; 21(1): 55. PMID 33827525

47. National Institute for Health and Care Excellence (NICE). Insertion of prostatic urethral lift implants to treat lower urinary tract symptoms secondary to benign prostatic hyperplasia [IPG475]. 2014; https://www.nice.org.uk/guidance/ipg475/chapter/1-recommendations. Accessed July 7, 2022.

48. National Institute for Health and Care Excellence (NICE). UroLift for treating lower urinary tract symptoms of benign prostatic hyperplasia [MTG58]. 2021; https://www.nice.org.uk/guidance/MTG58. Accessed July 7, 2022.

    Prostate Cancer

49. The 2022 AUA/ASTRO guidelines for clinically localized prostate cancer from which are endorsed by the Society of Urologic Oncology (SUO).

50. American Urological Association (AUA), the American Society of Clinical Oncology (ASCO), the American Society for Radiation Oncology (ASTRO), and the Society of Urologic Oncology (SUO), 2017 joint practice guideline.

51. The National Comprehensive Cancer Network (NCCN) Clinical practice guidelines for the treatment of prostate cancer.

52. Overview of Focal Laser Ablation, a Type of Laser Treatment, for Prostate Cancer. https://www.healthline.com/health/prostate-cancer/laser-prostate-cancer-treatment#risks-and-side- effects.

    Policy Implementation

    Approved by the Medical and Pharmacy Policy Committee

    Kate McIntosh MD MBA

    Chief Medical Officer

    Saad Usmani MD MBA

    Medical Director

19

Date Update 11/2023 New policy effective 2/1/2024 2/2024 Updated Line of Business Section 4/2024 Removed LCD L37808 06/2024 Descriptions updated. Removed LCD L37485. Added criteria for prostatic urethral lift to the prostate cancer section. Criteria reordered with no changes. Added CPT 53855 as Experimental/Investigational. 05/2025 High Intensity Focused Ultrasound (HIFU) made Experimental/Investigational due to lack of high-quality evidence. IQ criteria titles updated to latest Iteration. Transperineal laser ablation (TPLA), Transurethral balloon dilatation for treatment of BPH and Urethral therapeutic drug delivery by drug-coated balloon catheter for urethral stricture or stenosis in males, added to the policy as Experimental/Investigational. Transperineal focal laser ablation (Tranberg Thermal Therapy System) added to the policy as an Experimental/Investigational procedure. Prostate Cancer references updated. Deleted HCPCS C9769, Added CPT 52284 and 0950T (Experimental/Investigational).

Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).
Health New England expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by Health New England, as some programs exclude coverage for services or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.