53865
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
3.02
Facility
$145.63
Non-Facility
$3086.58
Documentation Required
- Evaluation of symptoms along with objective findings from examination and laboratory results (policy text: 'Treatment of BPH is individualized to the patient and involves evaluation of symptoms along with objective findings from examination and laboratory results').
- Medical record documentation supporting the diagnosis of BPH and the clinical scenario indicating surgery (e.g., moderate-to-severe LUTS refractory to medical management, renal insufficiency secondary to BPH, refractory urinary retention, recurrent UTIs, recurrent bladder stones, gross hematuria due to BPH).
- Documentation that demonstrates prior medical therapy and response (policy notes initial treatment is usually drug therapy and that up to 30% of patients require surgical intervention).
- Use of appropriate and current procedure and diagnosis codes when submitting claims; claims without covered codes under the Coverage Policy will be denied (policy: 'must use the most appropriate codes as of the effective date of the submission').
Key Coverage Criteria
- Surgical and minimally invasive procedures used in the treatment of benign prostatic hyperplasia (BPH).
- Surgery for patients with renal insufficiency secondary to BPH (per AUA recommendation).
- Surgery for refractory urinary retention secondary to BPH (per AUA recommendation).
- Surgery for recurrent urinary tract infections (UTIs) due to BPH (per AUA recommendation).
- Surgery for recurrent bladder stones due to BPH (per AUA recommendation).
- Surgery for gross hematuria due to BPH (per AUA recommendation).
6 Active Policies
CIGNA-BPH — Benign Prostatic Hyperplasia (BPH) Surgical Treatments - (0159)
BCBSIL-MED201.025 — Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic Hyperplasia
BCBSMT-MED201.025 — Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic Hyperplasia
BCBSNM-MED201.025 — Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic Hyperplasia
BCBSOK-MED201.025
Related Codes
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