Transurethral Waterjet Ablation of the Prostate

Transurethral waterjet ablation of the prostate is covered once for patients with LUTS due to BPH who meet all criteria: TRUS prostate volume 30–150 cc, IPSS ≥12, Qmax ≤15 mL/s with voided volume >125 cc, and failure/contraindication/intolerance to ≥3 months of conventional medical therapy. Coverage requires use of an FDA-approved device, absence of listed exclusions (e.g., BMI ≥42, prostate or bladder cancer, active infection, urethral strictures, damaged sphincter, inability to stop anticoagulants), documentation of provider credentials, and supporting diagnostic and treatment records; audits may be performed.

"Transurethral waterjet ablation is reasonable and necessary for treatment of LUTS due to BPH when ALL criteria below are met."

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