CurrentBlue Cross Blue Shield - North CarolinaPolicy N/A

Request for Services Form — Prostatic Urethral Lift (PUL)

A provider-facing request-for-services/prior review form used by BCBSNC to request authorization for prostatic urethral lift procedures; applies to North Carolina providers and members and documents clinical and administrative information required for prospective review.

Policy Summary

PayerBlue Cross Blue Shield - North Carolina

PolicyRequest for Services Form — Prostatic Urethral Lift (PUL)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed prior authorization request and supporting records to BCBSNC for prospective review before the procedure.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1page count indicated

45+minimum age listed

≤80ccprostate volume threshold

3required attestations

Coverage Criteria — Prostatic Urethral Lift (PUL)

Prostatic Urethral Lift — Candidate and documentation criteria

Considered when ALL of the following are met:

PUL candidate criteria: Patient is age ≥45 AND has moderate-to-severe lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH).

Procedure candidacy and symptom course: Patient is not a candidate for invasive surgical procedure (e.g., TURP) OR has opted for a minimally invasive procedure; if yes, patient has persistent or progressive LUTS.

Medical therapy trial: Appropriate trial of medical therapy defined as either 1 month of an alpha-1–adrenergic antagonist OR 6 months of a 5‑alpha‑reductase inhibitor without significant side effects, or patient is unable to tolerate medical therapy (supporting records of failed medical therapy must be submitted).

Policy Summary

PayerBlue Cross Blue Shield - North Carolina

PolicyRequest for Services Form — Prostatic Urethral Lift (PUL)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed prior authorization request and supporting records to BCBSNC for prospective review before the procedure.

SourceLink

On This Page

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Coding — Diagnosis, Device, and Related Fields

Diagnosis codes (form fields)ICD-10

ICD-10 fields

The form includes fields for primary and other diagnosis ICD-10 codes (exact codes not specified on form).

Device identifiermixed

Device name field

Field for name of FDA-approved urethral lift device system to be used (device-specific codes not listed).

inv-06: Prostate volume — value threshold (≤ 80 cc)

Prostate volume thresholdProstate gland volume estimated to be ≤ 80 cc on ultrasound or other radiological assessment

Measurement methodEstimated on ultrasound or other radiological assessment as specified on the form

Attestation requirementProvider must attest on the form that prostate volume is ≤ 80 cc

Provider Actions and Submission Requirements

Prior Authorization

Prior Authorization Required

Prospective prior authorization is required for all requests. Submission of the Request for Services form is notification only and does not guarantee approval — all requests must be reviewed and authorized through BCBSNC prior to services being rendered.

All requests require prospective review and authorization through BCBSNC
Incomplete forms may delay processing and do not guarantee approval

Note

Provider Actions — Submission Workflow

Fax the completed form with required supporting documentation to the appropriate BCBSNC department. Ensure the ordering physician is trained in Urology and include the name of the FDA‑approved urethral lift device system to be used.

Discharge Services Fax Numbers: 800.228.0838; 800.795.9403
PPA/Case Mgmt/Acute Inpt Fax Numbers: 800.571.7942; 866.225.5258; 800.672.6587; 919.765.1553; 800.459.1410

Documentation Required

Supporting Records and Attestation

Submit supporting medical records to document failed medical therapy or intolerance where applicable. BCBSNC may request medical records at any time to verify attested information; attestations must be reflected in the patient’s medical record.

Provide records documenting trial and outcome of alpha‑1‑adrenergic antagonist and/or 5‑alpha‑reductase inhibitor therapy when indicated
Be prepared to provide records that verify any attested clinical findings or contraindications

Denial Risk

Submission / Completeness Risk

The form must be complete to avoid processing delays. Submission of an incomplete form is notification only and may delay review; include the patient’s BCBSNC member ID, date of birth, primary diagnosis with ICD‑10 code, prostate volume and anatomy assessment, prostate cancer testing status, and physician signature/attestation.

All NC Providers must provide their 5‑digit BCBSNC provider ID#
Include date of last prostate screening and documentation of prostate gland volume (≤ 80 cc) and median lobe status

Definitions and Eligibility Thresholds

inv-12: Appropriate trial of medical therapy — defined durations for alpha-1 antagonist and 5-alpha-reductase inhibitor

Alpha-1 adrenergic antagonist durationDefined as one month of therapy

5-alpha-reductase inhibitor durationDefined as six months of therapy

Failed therapy documentationIf patient cannot tolerate or has failed medical therapy, submit supporting medical records as requested on the form

inv-13: Prostatic urethral lift candidate age — patient aged 45 years or older

Minimum agePatient is 45 years of age or older

Associated clinical requirementPatient must have moderate-to-severe lower urinary tract obstruction due to BPH (attested on form)

Ordering clinicianRequest must be ordered by a physician trained in the specialty of Urology (attested on form)

Background

This request-for-services form is specific to authorization requests for prostatic urethral lift (PUL) in adult men with moderate-to-severe lower urinary tract symptoms due to benign prostatic hyperplasia (BPH). The form documents required candidate elements including age (≥45 years), confirmation of moderate-to-severe LUTS from BPH, prior medical therapy trial or intolerance, prostate volume threshold (≤ 80 cc), absence of obstructive/protruding median lobe anatomy, exclusion of prostate cancer by appropriate testing, identification of an FDA‑approved urethral lift device, and physician attestation by a urology‑trained provider.