Transurethral Waterjet Ablation of the Prostate

Transurethral waterjet ablation of the prostate is covered when treating LUTS due to BPH using an FDA‑approved/cleared device in patients with prostate volume 30–150 mL, IPSS ≥12, Qmax ≤15 mL/s, and failure/intolerance/contraindication to ≥3 months of conventional medical therapy. Coverage is denied for multiple specific exclusions (e.g., BMI ≥42 kg/m², known or suspected prostate cancer without recent negative biopsy, bladder pathology, active infection, urethral strictures, damaged sphincter, device allergy, or inability to stop anticoagulants), the procedure is limited to one lifetime use, and documentation of objective measures and provider credentialing is required.

"Transurethral waterjet ablation is covered for treatment of lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) when performed using an FDA‑approved/cleared device."