CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Transurethral Water Jet Ablation (Aquablation) for Benign Prostatic Hypertrophy

Commercial product coverage policy for transurethral waterjet ablation (Aquablation) to treat lower urinary tract symptoms/benign prostatic hyperplasia (LUTS/BPH); defines indications, contraindications, device requirement, prior authorization recommendation, and applicable CPT/HCPCS codes for Commercial Plans only.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyTransurethral Water Jet Ablation (Aquablation) for Benign Prostatic Hypertrophy

Policy CodePolicy N/A

Change TypeCoding update (new code 52597deletion of 0421T)

Effective Date03/01/2026

Next Review DateN/A

Key ActionPrior authorization is recommended and providers must document prostate volume (30-150 cc), IPSS ≥12, Qmax ≤15 mL/s, trial/failure/contraindication/intolerance to ≥3 months of conventional therapy, absence of exclusions, and use of an FDA approved/cleared device.

SourceLink

POLICY UPDATE CHANGES

New CPT code 52597 effective 1/1/2026 is listed as medically necessary; CPT code 0421T deleted effective 12/31/2025.

1Procedure allowed once

30-150 ccProstate volume range

>=12IPSS threshold

<=15 mL/s

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Coverage Summary

This policy is a Commercial product coverage policy for transurethral waterjet ablation (Aquablation) to treat lower urinary tract symptoms/benign prostatic hyperplasia (LUTS/BPH). Coverage stance: covered with criteria. Effective date: 03/01/2026; Last review: 11/19/2025. This policy applies to Commercial Products only (Medicare Advantage has a related policy).

Quick Facts & Thresholds

Prostate volume30-150 cc

IPSS threshold>= 12

Qmax threshold<= 15 mL/s

Conventional medical therapy duration>= 3 months

Procedure allowedOnce

Medical Necessity Criteria (Commercial Products)

Commercial Products - Not Medically Necessary

Commercial Products - Not medically necessary when the medical criteria above have not been met.

Not Medically Necessary: Any service for Aquablation when the specified medical criteria (Indications, FDA device requirement, and absence of exclusion criteria) are not met.

Includes CPT coding guidance: medically necessary CPT 52597 when criteria met; 0421T deleted 12/31/2025.

Coding

Deleted / Not Applicable CodesCPT|HCPCSNot Covered

0421T

Transurethral waterjet ablation of prostate, including control of post-operative bleeding, including ultrasound guidance, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when performed) (Code Deleted Effective 12/31/2025)

Provider Actions

Prior Authorization

Prior Authorization Recommended

Prior authorization is recommended for transurethral waterjet ablation (aquablation) for Commercial Products. Codes: []

Documentation Required

Document Medical Necessity Criteria

Provider must document prostate volume (30-150 cc), IPSS score (≥12), Qmax (≤15 mL/s), and trial/failure/contraindication/intolerance to at least three months of conventional medical therapy; document absence of listed exclusions and that only an FDA approved/cleared device was used.

Prostate volume 30-150 cc
International Prostate Symptom Score (IPSS) ≥ 12
Maximum urinary flow rate (Qmax) ≤ 15 mL/s
Trial, failure, contraindication, or intolerance to ≥ 3 months of conventional medical therapy for LUTS/BPH
Documentation of absence of exclusion criteria (e.g., BMI ≥42 kg/m2; known/suspected prostate cancer or PSA >10 ng/mL without recent negative biopsy; bladder cancer, neurogenic bladder, bladder calculus, significant bladder diverticulum; active infection; chronic prostatitis treatment; urethral stricture/meatal stenosis/bladder neck contracture; damaged external urinary sphincter; allergy to device materials; inability to stop anticoagulants/antiplatelets)

Background & Evidence

Aquablation (transurethral waterjet ablation) is a minimally invasive fluid jet prostate tissue resection technique investigated as an alternative to TURP. The Aquabeam® System (Procept Robotics Corporation) was cleared by the FDA through the de novo classification process (DEN170024) in April 2017. This policy applies to Commercial Products only; Medicare Advantage has a related policy. Relevant CPT coding updates: New CPT code 52597 effective 01/01/2026 is listed as medically necessary when criteria are met; 0421T is deleted effective 12/31/2025.

Source	Detail
FDA Clearance
Aquabeam System de novo DEN170024 (cleared for marketing April 2017); device intended for resection and removal of prostate tissue in males with LUTS due to BPH
Key RCT
WATER randomized trials and follow-up publications (Gilling et al.) including J Urol 2018 and Urology 2019 randomized trials and three-year outcomes publications
Local Coverage Determination
CMS LCD L38367 and Billing Article A56797 referenced for Fluid Jet System Treatment for LUTS/BPH

Definitions

Aquablation / Fluid jet system treatmentTransurethral waterjet ablation that cuts prostate tissue using a pressurized jet of fluid (may be referred to as Aquablation or Aquabeam system).

IPSSInternational Prostate Symptom Score; threshold for policy is >=12 indicating moderate to severe symptoms.

QmaxMaximum urinary flow rate (mL/s); threshold for policy is <=15 mL/s.

Medicare Determinations

Name	Number	Type	Effective Date
Fluid Jet System Treatment for LUTS/BPH
L38367
LCD

Billing and Coding: Fluid Jet System Treatment for LUTS/BPH
A56797
LCD

Revision History

2026-03-01policy_effectiveLatest

Policy effective date for Commercial Products set to 2026-03-01 (Medical Coverage Policy for Transurethral Water Jet Ablation - Aquablation).

2025-11-19last_review

Policy last reviewed on 2025-11-19.

2026-01-01coding_update