52647
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The medical record must document assessment by the ordering provider related to the patient's complaint for that visit and evidence supporting medical necessity for laser ablation.
- The medical record must include relevant medical history and duration of BPH.
- Document the American Urological Association (AUA) symptom index score in the medical record.
- Document results of urodynamics studies and/or post-void residual volume when these tests are performed.
Key Coverage Criteria
- Laser ablation of the prostate is covered when the medical record documents medical necessity for treatment of benign prostatic hyperplasia (BPH) in accordance with LCD L34090.
- Laser prostatectomy is indicated for patients with bladder neck obstruction secondary to benign prostatic hyperplasia (BPH).
- BPH symptoms of duration 3 months or longer prior to consideration of laser therapy.
- American Urological Association (AUA) symptom score greater than 9 supports coverage for laser prostate procedures.
- Urodynamics and post-void residual (PVR) testing should be performed and documented as appropriate, particularly for patients with suspected neurologic disease or those who have failed prior prostate surgery.
- Laser enucleation techniques (e.g., HoLEP) may be used for a subset of patients with markedly enlarged prostates who require prostate surgery.
3 Active Policies
A56467 — Billing and Coding: Laser Ablation of the Prostate
L34090 — Laser Ablation of the Prostate
AETNA-CPB-0079 — Benign Prostatic Hyperplasia
Related Codes
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