Transurethral Waterjet Ablation of the Prostate

Transurethral waterjet ablation of the prostate is covered only once per patient when performed with an FDA‑approved/cleared device for LUTS/BPH in patients who meet all criteria: prostate volume 30–150 mL, IPSS ≥12, Qmax ≤15 mL/s, and documented failure/contraindication/intolerance to ≥3 months of conventional medical therapy. Coverage is excluded for specified conditions (e.g., BMI ≥42 kg/m2, active infection, bladder pathology, urethral strictures, damaged external sphincter, chronic prostatitis), for suspected or known prostate cancer unless a recent negative biopsy supports treatment, and when anticoagulation cannot be safely managed; providers must be appropriately credentialed and claims may be audited.

"Transurethral waterjet ablation of the prostate is covered only when performed using an FDA‑approved or FDA‑cleared device."

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