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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that benign prostatic hyperplasia (BPH) is a histological diagnosis characterized by 
an increased number of epithelial and stromal cells in the prostate. It is common in men over the age of 40, and 
the incidence increases with age. In the United States, 8 million men older than 50 years old suffer from BPH. 
In many cases BPH is asymptomatic, however, symptoms may occur with prostate enlargement and 
compression of the urethra leading to bothersome lower urinary tract symptoms (LUTS), including voiding 
symptoms such as hesitancy, weak stream, straining, prolonged voiding, and storage symptoms (frequency, 
urgency, and nocturia). LUTS/BPH can have a significant impact on the quality of life and can cause serious 
complications such as infections, bleeding, calculus formation, urinary retention and decline of renal function 
when untreated.1 First line treatment generally consists of treatment with medications such as alpha blockers, 
PDE5 Inhibitors, or finasteride/dutasteride. If treatment with medications is not successful, surgical options 
may then be considered. Transurethral resection of the prostate (TURP) and open simple prostatectomy (OSP) 
are the standard surgical treatments for LUTS/BPH and are highly effective and provide improved outcomes in 
urinary functions. However, neither TURP nor OSP are without considerable perioperative complication and 
morbidity.2 Recently, new minimally invasive surgeries have emerged as alternatives for the resection of the 
prostate to manage LUTS in men with BPH. One such surgery is transurethral waterjet ablation which is 
minimally invasive; water based surgical therapy that combines image guidance and robotics to remove 
prostatic tissue.3 The system works by pumping high pressure saline (500 to 8000 pounds per square [PSI]) 
through a probe nozzle to cut and dissect tissue at predetermined system parameters. 
 
Treatment for LUTS/BPH treatment will be considered reasonable and necessary when performed once in 
patients with the following: 
 
    1. Indications including ALL of the following: 
        a. Age =80 
        b. Prostate volume of 30-150 cc by transrectal ultrasound (TRUS)4,5 
        c. Persistent moderate to severe symptoms despite maximal medical management 
 
including ALL of the following: 
             i. International Prostate Symptom Score (IPSS) =124 
           ii. Maximum urinary flow rate (Qmax) of =15 mL/s4 (voided volume greater than 125 cc) 
          iii. Failure, contraindication or intolerance to at least three months of conventional medical therapy for 
LUTS/BPH (e.g., alpha blocker, PDE5 Inhibitor, finasteride/dutasteride) 
 
2. Only treatment using an FDA approved/cleared device will be considered reasonable and necessary. 
 
The following are considered not reasonable and necessary: 
 
    1. Body mass index = 42kg/m26 
    2. Known or suspected prostate cancer (based on NCCN Prostate Cancer Early Detection guidelines7) or a 
prostate specific antigen (PSA) >10 ng/mL unless the patient has had a negative prostate biopsy within the last 
6 months. 
    3. Bladder cancer, neurogenic bladder, bladder calculus or clinically significant bladder diverticulum6 
    4. Active urinary tract or systemic infection8 
    5. Treatment for chronic prostatitis6 
    6. Diagnosis of urethral stricture, meatal stenosis, or bladder neck contracture6 
    7. Damaged external urinary sphincter6 
    8. Known allergy to device materials8 
    9. Inability to safely stop anticoagulants or antiplatelet agents preoperatively.8 
 
Notice: Services performed for any given diagnosis must meet all of the indications and limitations stated in 
this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and 
all existing CMS national coverage determinations, and all Medicare payment rules. 
 
You can find this information in the Local Coverage Determination (LCD) L38705. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.