About this policy
Jurisdiction: J6 MAC Part B. States: Illinois, Minnesota, Wisconsin. Type: Active LCD
Coverage indications
This LCD addresses use of the fluid jet system treatment of lower urinary tract symptoms attributable to benign prostatic hyperplasia (LUTS/BPH). Indications Treatment for LUTS/BPH will be considered reasonable and necessary when performed ONCE in patients with the following: Indications including ALL of the following: Prostate volume of 30-150 cc 1,2 Persistent moderate to severe symptoms despite maximal medical management including ALL of the following: International Prostate Symptom Score (IPSS) ≥12 1 Maximum urinary flow rate (Qmax) of ≤15 mL/s 1 Failure, contraindication or intolerance to at least three months of conventional medical therapy for LUTS/BPH (e.g., alpha blocker, PDE5 Inhibitor, finasteride/dutasteride) Only treatment using an FDA approved/cleared device will be considered reasonable and necessary. Limitations The following are considered not reasonable and necessary: Body mass index ≥ 42kg/m2 Known or suspected prostate cancer (based on NCCN Prostate Cancer Early Detection guidelines 4 ) or a prostate specific antigen (PSA) > 10 ng/mL unless the patient has had a negative prostate biopsy within the last 6 months. Bladder cancer, neurogenic bladder, bladder calculus or clinically significant bladder diverticulum 3 Active urinary tract or systemic infection 5 Treatment for chronic prostatitis 3 Diagnosis of urethral stricture, meatal stenosis, or bladder neck contracture 3 Damaged external urinary sphincter 3 Known allergy to device materials 5 Inability to safely stop anticoagulants or antiplatelet agents preoperatively. 5
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.