Fluid Jet System in the Treatment of Benign Prostatic Hyperplasia (BPH)

Transurethral waterjet ablation for LUTS due to BPH is covered when performed once with an FDA‑approved/cleared device in patients with prostate volume 30–150 mL, IPSS ≥12, Qmax ≤15 mL/s, and failure/intolerance/contraindication to at least three months of medical therapy. Coverage is denied for multiple specific exclusions including BMI ≥42 kg/m2, known or suspected prostate cancer without a negative biopsy within 6 months (or PSA >10 ng/mL without negative biopsy), active infections, significant bladder pathology, chronic prostatitis, urethral/bladder outlet strictures, damaged external sphincter, known device material allergy, and inability to safely stop anticoagulants/antiplatelets; provider credentialing and documentation of the required tests and prior therapy must be retained.

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