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    v1.0.28
    OpenPayerPolicy UpdatesUrologyAmeriHealth Caritas UroLift Coverage Update | Open…
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    CurrentAmeriHealth CaritasPolicy CCP.1529

    Prostatic urethral lift (UroLift) for benign prostatic hyperplasia

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    Defines AmeriHealth Caritas coverage and medical necessity criteria for prostatic urethral lift (UroLift) to treat lower urinary tract symptoms from benign prostatic hyperplasia; applies to plan-covered members and providers submitting requests to AmeriHealth Caritas.

    Policy Summary
    PayerAmeriHealth Caritas
    PolicyProstatic urethral lift (UroLift) for benign prostatic hyperplasia
    Policy CodePolicy CCP.1529
    Change TypeRevised medical necessity criteria
    Effective DateAug 1, 2023
    Last ReviewAug 1, 2025
    Next Review DateDec 1, 202639d
    Key ActionObtain prior authorization and document prostate volume (30–80 cc) and absence of an obstructive median lobe for routine coverage.
    SourceLink
    POLICY UPDATE CHANGES

    Medical necessity criteria were revised to align with current American Urological Association guideline recommendations by deleting the age criterion and the requirement of medication failure.

    Coverage section updated based on the American Urological Association guideline; findings section reorganized and new systematic reviews were added.

    30–80 ccRoutine coverage range
    81–100 ccLimited evidence / case-by-case
    >100 ccContraindicated

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    preserve sexual functionPreserve sexual function
    ~6%/yrAnnual reintervention

    Coverage and Medical Necessity Criteria

    Initial therapy / Coverage criteria

    Covered when ALL of the following are met:

    Core coverage criteria: Member has a prostate volume between 30 and 80 ccprostate 30-80 cc

    Based on AUA guideline recommendations and L.I.F.T. trial inclusion criteria.

    Core coverage criteria: Verified absence of an obstructive median lobe of the prostate

    Verified absence of an obstructive median lobe per AUA guidance.

    Conditional / case-by-case

    May be considered on a case-by-case basis when ANY of the following apply:

    Case-by-case scenarios: Prostate volume greater than 80 cc and up to 100 cc81-100 cc

    Limited evidence supports improved outcomes; requires individualized review.

    Case-by-case scenarios: Presence of an obstructive median lobe

    Evidence is limited; consider on a case-by-case basis and document individualized justification.

    The prostatic urethral lift (UroLift) is contraindicated for members with a prostate volume >100 cc. Other contraindications that would make the procedure not appropriate and may lead to denial include an active urinary tract infection, urinary incontinence, current gross hematuria, urethral conditions that prevent insertion of the delivery system, and a known allergy to nickel.

    Evidence supports routine use of prostatic urethral lift/UroLift primarily for patients with prostate volumes between 30 and 80 cc without obstructive median lobes, based on the randomized L.I.F.T. trial and guideline-aligned literature. For patients with prostate volumes >80 cc up to 100 cc or with an obstructive median lobe, published evidence is limited; such cases should be reviewed on a case-by-case basis and individually justified before approval. Observational and single-arm studies (for example, the MedLift prospective series) show promising but insufficient data to establish routine effectiveness for median lobes.

    When counseling providers and reviewers, consider that surgical reintervention after UroLift is an important outcome: pooled analyses report an approximate annual surgical reintervention rate of 6% per year. This higher reintervention rate compared with other options and higher five-year costs in some analyses underscore the need to weigh long-term outcomes and potential for retreatment when considering UroLift outside the routine 30–80 cc population.

    Coding and Prostate Volume Summary

    No explicit CPT/HCPCS/ICD-10 codes listedmixed
    No codes listed
    Prostate volume
    Routine coverage rangeProstate volume 30–80 cc (covered when all other criteria met)
    Limited-evidence / case-by-case rangeProstate volume 81–100 cc (may be considered on a case-by-case basis)
    Contraindicated volume>100 cc (procedure is contraindicated)

    Prior Authorization, Documentation, and Denial Conditions

    Prior Authorization

    Prior authorization required; approval when criteria met

    Prior authorization is required for prostatic urethral lift (UroLift). Approval is granted when the medical necessity criteria are met — specifically, the member has a prostate volume between 30 and 80 cc and there is verified absence of an obstructive median lobe; cases with prostate volume 81–100 cc or an obstructive median lobe are reviewed on a case-by-case basis.

    • Prior authorization must document prostate volume measurement and assessment for obstructive median lobe.
    • Requests for volumes 81–100 cc or with an obstructive median lobe require individualized case-by-case review.
    Step Therapy

    No medication failure required prior to UroLift

    Medication failure is not required before proceeding with UroLift; proceeding without prior medical therapy may be appropriate and can be part of informed decision-making between the clinician and patient.

    • Discussing medical therapy is appropriate, but trial of medications is not an absolute requirement for intervention.

    Clinical Background

    Benign prostatic hyperplasia (BPH) is a common, nonmalignant enlargement of the prostate that can produce lower urinary tract symptoms, incomplete bladder emptying, urinary retention, and increased risk of urinary tract infection. Conservative treatments include alpha blockers, 5-alpha reductase inhibitors, and other medical therapies, which may be ineffective or have adverse effects for some patients. The prostatic urethral lift (UroLift) is an endoscopic implant-based procedure that retracts obstructing prostatic lobes to create and maintain a channel from the bladder neck to the verumontanum, typically using multiple small implants; it is intended to relieve obstruction while preserving erectile and ejaculatory function and can be performed with local or general anesthesia.

    Device and Regulatory Definitions

    Prostatic urethral lift (UroLift) — device and procedure
    Implant compositionEach implant consists of a capsular nitinol tab and a urethral stainless steel tab connected by a non-absorbable suture
    Delivery systemImplants are delivered via a disposable cartridge during an endoscopic transurethral procedure
    Mechanism and procedureImplants retract obstructing prostatic lobes to create an open channel from bladder neck to verumontanum, typically requiring three to four implants
    Anesthesia and settingPerformed under local or general anesthesia in inpatient or outpatient settings
    FDA indication history
    Original FDA approval (2013)UroLift System UL400 approved for patients ≥50 years with no obstructive median or lateral lobe and prostate volumes 30–80 cc

    Policy Changes and Revision History

    2025revisedLatest

    Updated references and revised medical necessity criteria to align with current American Urological Association guideline recommendations; removed the age criterion and the requirement of medication failure.

    2024revised

    Revised the coverage section based on updated AUA clinical guidelines, reorganized the findings section, and added new systematic reviews.

    2023-08-01effective_date
    Policy Summary
    PayerAmeriHealth Caritas
    PolicyProstatic urethral lift (UroLift) for benign prostatic hyperplasia
    Policy CodePolicy CCP.1529
    Change TypeRevised medical necessity criteria
    Effective DateAug 1, 2023
    Last ReviewAug 1, 2025
    Next Review DateDec 1, 202639d
    Key ActionObtain prior authorization and document prostate volume (30–80 cc) and absence of an obstructive median lobe for routine coverage.
    SourceLink
    On This Page
    Coverage and Medical Necessity CriteriaCoding and Prostate Volume SummaryPrior Authorization, Documentation, and Denial ConditionsClinical BackgroundDevice and Regulatory DefinitionsPolicy Changes and Revision History
    Documentation Required

    Verify prostate volume 30–80 cc and document absence of obstructive median lobe

    Document objective prostate volume measurement showing 30–80 cc and record verified absence of an obstructive median lobe; when relevant, document the patient’s desire to preserve erectile and ejaculatory function.

    • Include the method and date of prostate volume measurement (e.g., imaging modality) in the record.
    • Explicitly state absence of an obstructive median lobe in the clinical documentation for routine coverage.
    Denial Risk

    Contraindications that may lead to denial

    Requests may be denied for contraindications including prostate volume >100 cc, active urinary tract infection, urinary incontinence, current gross hematuria, urethral conditions preventing device insertion, or known nickel allergy.

    • Do not submit authorization requests for members with prostate volume >100 cc — these are listed as contraindications.
    • Active UTI, urinary incontinence, gross hematuria, urethral insertion barriers, or known nickel allergy are contraindications that can trigger denial.
    Expanded approval (2017)Approval expanded to include the UL500 model for lateral and median lobe prostate hyperplasia
    Further expansions (2019 onward)Subsequent models approved based on substantial equivalence, including individuals with prostate volumes up to 100 cc and patients aged ≥45 years

    Policy effective date set for revised coverage criteria (aligned with AUA guidance).