Fluid Jet System in the Treatment of Benign Prostatic Hyperplasia (BPH)

Transurethral waterjet ablation for LUTS due to BPH is covered when performed using an FDA-approved/cleared device in patients with prostate volume 30–150 mL, IPSS ≥12, Qmax ≤15 mL/s, and documented failure/contraindication/intolerance to at least three months of conventional medical therapy. Coverage is denied for several exclusions including BMI ≥42 kg/m2, known or suspected prostate cancer without a recent negative biopsy (PSA >10 ng/mL unless biopsy negative within 6 months), active infection, certain bladder/urethral pathologies, damaged external urinary sphincter, allergy to device materials, and inability to stop anticoagulation; the procedure is authorized only once per patient and requires documentation of provider credentialing and supporting medical records.

"Transurethral waterjet ablation is covered when performed using an FDA-approved or FDA-cleared device."