Transurethral Waterjet Ablation of the Prostate

Transurethral waterjet ablation of the prostate is covered when performed with an FDA-cleared device ONCE in patients with BPH who have prostate volume 30–150 mL, IPSS ≥12, Qmax ≤15 mL/s, and documented failure/intolerance/contraindication to ≥3 months of conventional medical therapy. Coverage is excluded for multiple conditions (e.g., BMI ≥42 kg/m², suspected/known prostate cancer without recent negative biopsy if PSA >10 ng/mL, active UTI, bladder pathology, urethral strictures, damaged sphincter, inability to hold anticoagulation, device allergy) and requires provider credentialing and specific documentation (IPSS, Qmax, prostate volume, medication history, PSA/biopsy when indicated, infection status, perioperative anticoagulation plan, and device/provider records).

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