Transurethral Waterjet Ablation of the Prostate

Transurethral waterjet ablation of the prostate is covered when performed with an FDA‑cleared device one time in patients with prostate volume 30–150 mL who have persistent moderate to severe LUTS (IPSS ≥12), Qmax ≤15 mL/s, and documented failure/intolerance/contraindication to ≥3 months of conventional medical therapy. Coverage is denied for patients with BMI ≥42 kg/m2, known or suspected prostate cancer (or PSA >10 ng/mL unless negative biopsy within 6 months), active infections, certain bladder or urethral pathologies, inability to stop anticoagulation, device material allergy, or when provider credentialing/training requirements are not met. Required documentation includes IPSS, Qmax uroflowmetry, prostate volume measurement, medication trial records, PSA/biopsy as indicated, infection status, BMI, exclusion assessments, device FDA clearance, and provider credentialing.

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