55874
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
2.95
Facility
$142.62
Non-Facility
$3704.49
Documentation Required
- For transurethral water jet ablation (Aquablation): documentation of LUTS due to BPH and that procedure is for resection/removal of prostate tissue for LUTS/BPH.
- "Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested; refer to the protocol titled Medical Records Documentation Used for Reviews."
- For cryoablation: documentation of recurrent prostate cancer diagnosed by biopsy (policy states cryoablation is proven and medically necessary for recurrent prostate cancer diagnosed by biopsy).
- For PUL: documentation that treatment is for 'symptoms due to urinary outflow obstruction secondary to BPH' (including lateral, with or without median lobe hyperplasia), patient age ≥45, prostate volume measurement to confirm not >100 cc, absence of urinary tract infection, absence of urethra conditions that would prevent device insertion, absence of urinary incontinence due to incompetent sphincter, and absence of current gross hematuria; and adherence to FDA labeled indications/contraindications/warnings/precautions.
Key Coverage Criteria
- Transurethral ablation of the prostate is proven and medically necessary in certain circumstances. For medical necessity clinical coverage criteria, refer to the InterQual® CP: Procedures, Prostatectomy, Transurethral Ablation.
- Cryoablation of the prostate is proven and medically necessary for recurrent prostate cancer diagnosed by biopsy.
- Prostatic urethral lift (PUL) is proven and medically necessary when performed according to the following U.S. Food and Drug Administration (FDA) labeled indications, contraindications, warnings, and precautions: Treating symptoms due to urinary outflow obstruction secondary to benign prostatic hyperplasia (BPH), including lateral, with or without median lobe hyperplasia, in men 45 years of age or older.
- High-energy water vapor thermotherapy for the treatment of benign prostatic hyperplasia (BPH) is proven and medically necessary in certain circumstances. For medical necessity clinical coverage criteria, refer to the InterQual® CP: Procedures, Prostatectomy, Transurethral Ablation.
- Transurethral water jet ablation of the prostate is proven and medically necessary for the resection and removal of prostate tissue for the treatment of lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia.
- Prostate artery embolization is proven and medically necessary for individuals with any of the following: Individuals with BPH who are ineligible for other procedures due to surgical constraints (i.e., prostate size) or anesthesia risk (i.e., comorbidities); Persistent gross hematuria originating from the prostate.
8 Active Policies
UHC-POL-prostate-surgery — Prostate Surgeries and Interventions
CARELON-perirectal-hydrogel-spacer-2021-11-07 — Perirectal Hydrogel Spacer
CARELON-perirectal-hydrogel-spacer-for-prostate-radiotherapy-2025-03-23 — Perirectal Hydrogel Spacer for Prostate Radiotherapy
CARELON-radiation-therapy-excludes-proton-2025-03-23 — Radiation Therapy Excludes Proton
Related Codes
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