K1011, Activation device for intraurethral drainage device with valve, replacement
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Records must be available for post-payment data analysis and medical review audits as required by Medicare program integrity provisions.
- Medical record must document prostate volume measurement (e.g., imaging or ultrasound) showing PV 30–150 mL.
- Medical record must document IPSS score demonstrating ≥ 12.
- Medical record must document uroflowmetry showing Qmax ≤ 15 mL/s.
Key Coverage Criteria
- All clinical inclusion criteria (PV 30–150 mL, IPSS ≥12, Qmax ≤15 mL/s, and failure/contraindication/intolerance to ≥3 months of conventional medical therapy) must be met for the procedure to be reasonable and necessary.
- Transurethral waterjet ablation is covered when performed using an FDA-approved or FDA-cleared device.
- Patient has a prostate volume (PV) between 30 and 150 mL.
- Patient has persistent moderate to severe LUTS due to benign prostatic hyperplasia as demonstrated by an International Prostate Symptom Score (IPSS) ≥ 12.
- Maximum urinary flow rate (Qmax) is ≤ 15 mL/s.
- Failure, contraindication, or intolerance to at least 3 months of conventional medical therapy for LUTS/BPH (for example, alpha blocker, PDE5 inhibitor, finasteride or dutasteride).
2 Active Policies
PALMETTO-JJ-L38549, Transurethral Waterjet Ablation of the Prostate
JJ
PALMETTO-JM-L38549, Transurethral WaterjetAblation of the Prostate
JM
Related Codes
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