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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 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. 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. 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. The system works by pumping high pressure saline (500 to 8000 pounds per square) through a 
probe nozzle to cut and dissect tissue at predetermined system parameters. 
 
Covered Indications 
 
Treatment for LUTS/BPH treatment will be considered reasonable and necessary when performed ONCE in 
patients with the following: 
 
Indications including ALL of the following: 
Age =80 
Prostate volume of 30-150 cubic centimeter (cc) by transrectal ultrasound (TRUS) 
Persistent moderate to severe symptoms despite maximal medical management 
including ALL of the following:  
International Prostate Symptom Score (IPSS) =12 
Maximum urinary flow rate (Qmax) of =15 milliliter (mL)/s (voided volume greater than 125 cc) 
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 a Food and Drug Administration (FDA) approved/cleared device will be considered 
reasonable and necessary. 
 
Limitations 
 
The following are considered not reasonable and necessary: 
 
Body mass index = 42 kilogram (kg)/m2 
Known or suspected prostate cancer (based on National Comprehensive Cancer Network (NCCN) Prostate 
Cancer Early Detection guidelines) 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 
Active urinary tract or systemic infection 
Treatment for chronic prostatitis 
Diagnosis of urethral stricture, meatal stenosis, or bladder neck contracture 
Damaged external urinary sphincter 
Known allergy to device materials 
Inability to safely stop anticoagulants or antiplatelet agents preoperatively. 
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 Center for Medicare and Medicaid 
Services (CMS) payment policy manuals, any and all existing CMS national coverage determinations, and all 
Medicare payment rules. 
 
You can find these rules in the Local Coverage Determination (LCD) Transurethral Waterjet Ablation of the 
Prostate L38707. 
 
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.