CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Prostatic Urethral Lifts (PUL) Coverage Criteria

This policy governs coverage and billing for prostatic urethral lift procedures (implant insertion) for Medicare Advantage and Commercial members of Blue Cross Blue Shield - Rhode Island.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyProstatic Urethral Lifts (PUL) Coverage Criteria

Policy CodePolicy N/A

Change TypeCoverage and coding additions

Effective DateJan 12, 2025

Next Review DateMar 9, 2025

Key ActionVerify member benefits and eligibility and document member agreement if proceeding with non-covered services.

SourceLink

POLICY UPDATE CHANGES

Effective 12/1/2025, Prostatic Urethral Lift is covered for both Medicare Advantage Plans and Commercial Products.

Specific CPT and HCPCS codes (52441, 52442, C9739, C9740) are listed as covered and do not require prior authorization effective 12/1/2025.

4procedure codes listed as covered

12/01/2025effective coverage date

No PA requiredPA stance for listed codes

Medicare & Commercialproduct types covered

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Coverage for Medicare Advantage and Commercial Products

Covered when provided to eligible members under Medicare Advantage Plans and Commercial Products per contract terms.

Coverage conditions: Procedure is a prostatic urethral lift using listed codes; patient is covered under Medicare Advantage or Commercial product; benefits and eligibility verified per member contract.

Benefits may vary by group/contract; refer to benefit booklet or subscriber agreement for applicable not medically necessary benefits/coverage.

Coverage for prostatic urethral lift procedures is provided for eligible members under the terms of their contract. Benefits and eligibility can vary by group and contract; providers must refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement to determine applicable coverage limitations and exclusions.

This policy does not replace the member-specific documents that govern benefits. For questions about an individual member's coverage or benefits, contact the provider call center and confirm eligibility and benefit limits before scheduling services.

The member's Evidence of Coverage or Subscriber Agreement governs determinations of medical necessity and covered benefits. If a service is determined to be not medically necessary or is a non-covered benefit under the member's plan, the service may be denied and could result in financial liability for the member unless the member has provided written agreement in advance to assume responsibility.

Providers should document verification of benefits and any written member agreement when proceeding with services that may be non-covered or not medically necessary, and follow contractual participation provisions described in applicable agreements.

Coding

Covered CPT CodesCPTCovered

52441	Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single implant
52442	Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; each additional permanent adjustable transprostatic implant (List separately in addition to code for primary procedure)

Covered HCPCS Codes (institutional)HCPCSCovered

C9739	Cystourethroscopy, with insertion of transprostatic implant; 1 to 3 implants (for institutional providers use only)
C9740	Cystourethroscopy, with insertion of transprostatic implant; 4 or more Implants (for institutional providers use only)

Provider Actions & Billing

Billing Rule

Prior Authorization Not Required

Prior authorization is not required for the listed codes for Medicare Advantage Plans and Commercial Products. This change is effective 2025-12-01.

Affected codes: 52441, 52442, C9739, C9740
Scope: Medicare Advantage Plans and Commercial Products
Effective date: 2025-12-01

Note

Verify Benefits & Eligibility

Verify member benefits and eligibility before providing services. Confirm the member's subscriber agreement or certificate and any employer agreement to determine coverage specifics.

Contact the provider call center for member-specific benefit information
Document verification of benefits in the patient record

Documentation Required

Document Member Agreement & Consent

Obtain and document the member's informed agreement when services may not be covered or may be denied. If a service is determined to be not medically necessary or a non-covered benefit, you may not bill the member unless you have provided advance written notice and obtained the member's written agreement to accept financial responsibility.

Obtain written member agreement before proceeding with non-covered or not medically necessary services
Retain the signed agreement in the medical record

Denial Risk

Denial Risk & Patient Liability

Services that are not covered or are not medically necessary may be denied. If denied, the member may be financially responsible if they signed an advance written agreement accepting liability. Verify coverage prior to service to minimize denial risk.

Denial risk if service is non-covered or not medically necessary
Potential patient financial responsibility only if advance written agreement is obtained

Background

Benign prostatic hyperplasia (BPH) is a common condition in older men that can produce lower urinary tract symptoms such as frequency, urgency, nocturia, and hesitancy. When surgical intervention is indicated to relieve obstruction, one minimally invasive option is the prostatic urethral lift.

The prostatic urethral lift (PUL) involves the insertion of one or more permanent implants into the prostate to retract obstructing prostatic tissue and maintain an expanded urethral lumen, thereby reducing urinary obstruction while avoiding tissue removal.

Definitions

Definition

TermProstatic urethral lift (PUL)

DefinitionInsertion of one or more permanent implants into the prostate to retract tissue and maintain urethral patency (expanded urethral lumen).

PurposeAlleviate lower urinary tract symptoms from benign prostatic hyperplasia by mechanically opening the prostatic urethra.

Procedure elementsPerformed via cystourethroscopy with placement of permanent transprostatic implants; may involve one or multiple implants depending on anatomy.