Transurethral Waterjet Ablation of the Prostate

Transurethral waterjet ablation of the prostate is covered one time when performed with an FDA‑approved/cleared device in patients with prostate volume 30–150 mL, persistent moderate to severe LUTS (IPSS ≥12 and Qmax ≤15 mL/s), and failure/contraindication/intolerance to at least 3 months of conventional medical therapy. Coverage is excluded for defined conditions including BMI ≥42 kg/m², known or suspected prostate cancer (or PSA >10 ng/mL without a negative biopsy within 6 months), active urinary/systemic infection, certain bladder or urethral pathologies, damaged external sphincter, allergy to device materials, inability to safely stop anticoagulants, and when performed by providers lacking appropriate credentialing; required clinical documentation and privileging must be maintained for audit.

"Transurethral waterjet ablation is covered when performed using an FDA‑approved/cleared device."