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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 inch [PSI]) 
through a probe nozzle to cut and dissect tissue at predetermined system parameters. 
 
Treatment for LUTS/BPH treatment will be considered medically reasonable and necessary when 
performed once in patients with the following: 
 
Indications including ALL of the following: 
Age 80 
Prostate volume of 30-150 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 mL/s (voided volume greater than 125 cubic centimeter (cc)) 
Failure, contraindication or intolerance to at least three months of conventional medical therapy for LUTS/BPH 
(e.g., alpha blocker, phosphodiesterase (PDE5) Inhibitor, finasteride/dutasteride) 
Only treatment using an Food and Drug Administration (FDA) approved/cleared device will be considered 
medically reasonable and necessary. 
 
The following are considered not medically reasonable and necessary: 
 
Body mass index  42kg/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. 
 
You can find these rules in the Local Coverage Determination (LCD) Transurethral Waterjet Ablation of the 
Prostate L38712. 
 
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.