Transurethral Waterjet Ablation of the Prostate

Transurethral waterjet ablation of the prostate is covered once per patient when performed with an FDA‑approved/cleared device by credentialed providers for men with LUTS/BPH who have prostate volume 30–150 mL, IPSS ≥12, Qmax ≤15 mL/s, and who have failed or are intolerant of ≥3 months of conventional medical therapy. Coverage is denied for patients with specified exclusions (e.g., BMI ≥42 kg/m2, suspected/known prostate cancer without required negative biopsy when PSA >10 ng/mL, active UTI, bladder pathology, urethral strictures, damaged external sphincter, chronic prostatitis, inability to stop anticoagulation, device material allergy), and documentation (IPSS, Qmax, prostate volume, medication history, PSA/biopsy when indicated, provider credentialing) must be maintained for audit and claim review.

"Procedure is covered only when performed with an FDA‑approved/cleared transurethral waterjet ablation device."