Fluid Jet System Treatment for LUTS/BPH

Fluid jet system treatment for LUTS due to BPH is covered once in patients with prostate volume 30–150 cc, IPSS ≥12, Qmax ≤15 mL/s, and documented failure/intolerance of ≥3 months of conventional medical therapy; treatment must use an FDA-approved/cleared device. Coverage is excluded for patients with BMI ≥42, active infections, known/suspected prostate cancer (or PSA >10 ng/mL without a negative biopsy within 6 months), several anatomic or bladder conditions (e.g., bladder cancer, neurogenic bladder, bladder calculus, diverticulum), urethral or sphincter damage, device allergies, or inability to safely stop anticoagulants/antiplatelets. Documentation should include TRUS prostate volume, IPSS, uroflowmetry Qmax, prior medical therapy history, infection status, anticoagulation management plan, device approval, and prostate biopsy pathology when indicated.

"Prostate volume 30-150 cc measured by transrectal ultrasound (TRUS)."