53866
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
1.44
Facility
$73.82
Non-Facility
$145.63
Documentation Required
- Record of symptom assessment including AUASI/IPSS score (e.g., ≥8 when indicating moderate-to-severe symptoms).
- Documentation of bothersome symptoms and impact on quality of life to justify initiating therapy.
- Clinical documentation of discussion of risks and benefits of medical therapy and rationale for initiating, continuing, or deferring treatment; if procedural therapy is planned, documentation of prior appropriate medical therapy trial.
- Uroflowmetry results documenting peak urinary flow rate (Qmax) with numeric value.
Key Coverage Criteria
- Symptomatic benign prostatic hyperplasia (BPH) causing prostatic urethral obstruction
- Prostatic cancer causing prostatic urethral obstruction
- Urinary retention or obstruction following radiation therapy to the prostate
- Short-term intraprostatic stenting to permit volitional voiding as an alternative to an indwelling Foley catheter
- Temporary intraprostatic stent as a minimally invasive alternative to transurethral resection of the prostate (TURP) for symptomatic BPH
- Benign prostatic hyperplasia presenting with lower urinary tract symptoms (LUTS) such as increased urinary frequency, nocturia, urgency, hesitancy, or weak urinary stream.
5 Active Policies
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 — Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic Hyperplasia
MED201.025
Related Codes
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