Transurethral Waterjet Ablation of the Prostate

Transurethral waterjet ablation of the prostate is reasonable and necessary when performed with an FDA‑approved/cleared device in patients with prostate volume 30–150 mL, IPSS ≥12, Qmax ≤15 mL/s, and documented failure/contraindication/intolerance to at least three months of conventional medical therapy. Coverage is excluded for several conditions (e.g., BMI ≥42, known or suspected prostate cancer without negative biopsy if PSA >10, bladder pathology, active infection, chronic prostatitis, urethral/urethral outlet abnormalities, damaged sphincter, allergy to device materials, or inability to stop anticoagulation), and the procedure must be performed by appropriately credentialed providers with required documentation of tests, therapy trials, and device clearance.

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