Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation (Aquablation) for Benign Prostatic Hyperplasia
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This policy governs BCBSNC coverage and medical necessity criteria for Rezūm (water vapor thermal therapy) and Aquablation (transurethral water jet ablation) for treatment of BPH in members meeting specified clinical and procedural criteria.
Coverage criteria for Transurethral Water Jet Ablation (Aquablation) were added to the policy.
Title changed to include both water vapor thermal therapy and water jet ablation; description and regulatory status updated.
Code 52597 was added to the billing/coding section effective 1/1/2026.
Title changed to include Transurethral Water Jet Ablation (Aquablation) and coverage criteria updated to include Transurethral Water Jet Ablation.
Description, regulatory status, policy statement, and policy guidelines were updated when Aquablation was added.
Coverage Criteria for Rezūm and Aquablation
Rezūm (water vapor thermal therapy) — Initial coverage
Covered when ALL of the following are met:
All five criteria must be met.
Aquablation (transurethral water jet ablation) — Initial coverage
Covered when ALL of the following are met:
All listed criteria must be met. Policy title and statement were updated to add Aquablation (see policy notice).
Covered with criteria (summary)
Summary — covered with criteria:
See full coverage criteria sections for the specific ALL/AND requirements for each procedure.
Repeat applications of transurethral water vapor thermal therapy (Rezūm) or transurethral water jet ablation (Aquablation) for benign prostatic hyperplasia are explicitly designated as investigational when used as repeat treatment. The policy also states that use of these therapies after prior minimally invasive BPH procedures (for example, a prostatic urethral lift) is considered investigational and may be denied if submitted for coverage.
The policy history documents that on 4/14/2020 three additional non-covered indications were added to the 'When Not Covered' section. The excerpts provided do not list those three specific indications in full; providers should consult the complete policy text for the detailed list of newly added non-covered conditions.
The policy makes clear that any application of transurethral water vapor thermal therapy or transurethral water jet ablation that does not meet the stated coverage criteria is considered investigational (not medically necessary) and is subject to denial.
Policy update notes indicate additions to the 'When Not Covered' section and other implementation changes, but the policy excerpts supplied here do not include the full text of those specific non‑medically‑necessary conditions. For precise exclusions and how they apply to individual cases, providers should refer to the full policy document and the policy change history.
Billing and Coding
Provider Actions and Documentation Requirements
Check prior authorization and applicable service codes
Prior authorization may be required for transurethral water vapor thermal therapy (Rezūm) or transurethral water jet ablation (Aquablation). Applicable service codes listed in the policy are 52597, 53854, 0421T, and C2596. Inclusion of a code in the Billing/Coding section does not guarantee reimbursement.
Document required medical therapy trial before procedure
An appropriate trial of medical therapy is required before considering coverage: patients must have completed one month following an alpha-1-adrenergic antagonist or three months following a 5‑alpha‑reductase inhibitor, unless there is intolerance or other contraindication.
- One month after an alpha-1‑adrenergic antagonist
- Three months after a 5‑alpha‑reductase inhibitor
- Or documented intolerance/contraindication to medical therapy
No additional step therapy pathways specified
The policy does not state any explicit step therapy program beyond the documented trial durations for alpha‑blockers and 5‑ARI; there are no additional step therapy requirements described in the provided document chunks.
- No explicit step therapy requirements stated in the policy excerpts
Be prepared to supply full medical records on request
BCBSNC may request medical records to determine medical necessity; when records are requested, letters of support or explanation are often useful but are not sufficient unless they include all specific information needed to make a medical necessity determination.
- Maintain and submit complete medical records when requested
- Letters alone are insufficient unless they contain all required information
Use current policy language and coding
Follow the updated policy language, regulatory status, and billing/coding sections when submitting claims and prior authorization requests, particularly after the 07/31/2024 notice adding Aquablation and codes 0421T/C2596 and the 01/01/2026 addition of code 52597.
- Adhere to revised policy statement and guidelines added 07/31/2024
- Use updated billing/coding listings when preparing claims and authorizations
Investigational indications may be denied
Requests for Rezūm or Aquablation that do not meet the policy coverage criteria (for example, repeat use, use after other minimally invasive BPH procedures, or use in patients with prostate cancer) are considered investigational and may be denied.
- Repeat use of these therapies is investigational
- Use after other minimally invasive BPH procedures (e.g., prostatic urethral lift) is investigational
- Use in patients with a diagnosis of prostate cancer is investigational
Background and Rationale
Benign prostatic hyperplasia (BPH) is a common condition in older men that can cause lower urinary tract symptoms (LUTS). Management includes medical therapy and, when appropriate, minimally invasive or surgical procedures. The policy record reflects the development and evolution of coverage for minimally invasive options (e.g., Rezūm), with periodic updates to indications, exclusions, and policy guidelines based on clinical review and Medical Director oversight.
Definitions
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