Laser Ablation of the Prostate

LCD Information Document Information Source LCD ID N/A LCD ID L34090 Original ICD-9 LCD ID Not Applicable LCD Title Laser Ablation of the Prostate Proposed LCD in Comment Period N/A Source Proposed LCD N/A Original Effective Date For services performed on or after 10/01/2015 Revision Effective Date For services performed on or after 04/02/2026 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date N/A Notice Period End Date N/A CPT codes, descriptions, and other data only are copyright 2025 American Medical Association. All Rights Reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association. 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Issue Issue Description This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations and/or Medical Necessity. Issue - Explanation of Change Between Proposed LCD and Final LCD CMS National Coverage Policy Language quoted from Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act (SSA): Section 1862(a)(1)(A) excludes expenses incurred for items or services, which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. National Coverage Determination 140.5 Laser Procedures Coverage Indications, Limitations, and/or Medical Necessity Abstract:Benign prostatic hyperplasia is an enlargement of the prostate gland that frequently occurs in men as they age. Current treatments include watchful waiting, medications i.e., alpha-blockers, and surgery. The gold standard for treating this condition is a transurethral resection of the prostate (TURP). Some patients may not be healthy enough to undergo this procedure and choose a less invasive procedure to treat this condition. This local coverage determination (LCD) addresses laser therapy of the prostate. Laser prostatectomy, or visual laser ablation of the prostate (VLAP) is an alternative technique to the conventional surgical intervention of transurethral resection of the prostate (TURP) in treating bladder outlet obstruction caused by benign prostate hypertrophy (BPH).Laser ablation of the prostate involves delivery of laser energy to the prostate in one of five main variations. These are: the transurethral ultrasound-guided laser-induced prostatectomy (TULIP), the free-fiber visually guided laser ablation of the prostate (VLAP), visually guided contact laser ablation of the prostate (CLAP), ultrasound guided interstitial laser coagulation of the prostate (ILCP), and the Holmium: YAG Laser (holmium laser ablation of the prostate -HoLAP, and holmium enucleation of the prostate - HoLEP). Laser enucleation of the prostate using a high power laser source is performed on a small subset of patients requiring prostate surgery due to the enlarged size of the prostate. A laser fiber is used to undermine and dissect away large pieces of prostate tissue that migrate into the bladder and are subsequently extracted at the end of the procedure. Indications:Laser prostatectomy is indicated as a treatment modality for patients with bladder neck obstruction secondary to benign prostatic hyperplasia (BPH). Laser surgery provides some advantages over traditional TURP in that the hospital stay is decreased, patients can resume normal activities quicker and morbidity is reduced.These procedures will be covered for the following indications: Duration of BPH 3 months or longer; American Urology Association (AUA) symptom score greater than 9 Urodynamics and Post-void Residual Volume examinations should be used as appropriate, e.g., patients with suspected neurologic disease or those who have failed prostate surgery. Limitations:A relative contraindication for these procedures is an active urinary infection.The use of these devices must be prescribed and administered under the personal supervision of a qualified and trained physician, after appropriate urological evaluation of the patient. The treating physician must be present at all times during the treatment. Summary of Evidence N/A Analysis of Evidence (Rationale for Determination) N/A

Abstract: Benign prostatic hyperplasia is an enlargement of the prostate gland that frequently occurs in men as they age. Current treatments include watchful waiting, medications i.e., alpha-blockers, and surgery. The gold standard for treating this condition is a transurethral resection of the prostate (TURP). Some patients may not be healthy enough to undergo this procedure and choose a less invasive procedure to treat this condition. This local coverage determination (LCD) addresses laser therapy of the prostate. Laser prostatectomy, or visual laser ablation of the prostate (VLAP) is an alternative technique to the conventional surgical intervention of transurethral resection of the prostate (TURP) in treating bladder outlet obstruction caused by benign prostate hypertrophy (BPH). Laser ablation of the prostate involves delivery of laser energy to the prostate in one of five main variations. These are: the transurethral ultrasound-guided laser-induced prostatectomy (TULIP), the free-fiber visually guided laser ablation of the prostate (VLAP), visually guided contact laser ablation of the prostate (CLAP), ultrasound guided interstitial laser coagulation of the prostate (ILCP), and the Holmium: YAG Laser (holmium laser ablation of the prostate -HoLAP, and holmium enucleation of the prostate - HoLEP). Laser enucleation of the prostate using a high power laser source is performed on a small subset of patients requiring prostate surgery due to the enlarged size of the prostate. A laser fiber is used to undermine and dissect away large pieces of prostate tissue that migrate into the bladder and are subsequently extracted at the end of the procedure. Indications: Laser prostatectomy is indicated as a treatment modality for patients with bladder neck obstruction secondary to benign prostatic hyperplasia (BPH). Laser surgery provides some advantages over traditional TURP in that the hospital stay is decreased, patients can resume normal activities quicker and morbidity is reduced. These procedures will be covered for the following indications: Duration of BPH 3 months or longer; American Urology Association (AUA) symptom score greater than 9 Urodynamics and Post-void Residual Volume examinations should be used as appropriate, e.g., patients with suspected neurologic disease or those who have failed prostate surgery. Limitations: A relative contraindication for these procedures is an active urinary infection. The use of these devices must be prescribed and administered under the personal supervision of a qualified and trained physician, after appropriate urological evaluation of the patient. The treating physician must be present at all times during the treatment.