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    v1.0.28
    OpenPayerPolicy UpdatesUrologyCareFirst UroLift® Coverage & Prior Auth | OpenPay…
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    CurrentCareFirstPolicy N/A

    Prostatic Urethral Lift (UroLift®) for Benign Prostatic Hypertrophy

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    Defines CareFirst coverage stance for the prostatic urethral lift (UroLift®) as a surgical treatment alternative for benign prostatic hypertrophy (BPH) when surgical intervention is indicated; applies to providers and members under CareFirst plans.

    Policy Summary
    PayerCareFirst
    PolicyProstatic Urethral Lift (UroLift®) for Benign Prostatic Hypertrophy
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateOct 1, 2025
    Last ReviewMay 14, 2025
    Next Review DateMay 14, 2025
    Key ActionSubmit preauthorization requests online or by phone and verify member contract benefits before performing the procedure.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    Up to 80 mLProstate size limit
    4-5Typical implants
    30%Men needing surgery
    RETIRED labelHeader status note

    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.

    Coverage Criteria

    Medically necessary — Prostatic urethral lift for BPH

    Covered when ALL of the following are met:

    Medically necessary indication: Surgical intervention is indicated for benign prostatic hypertrophy and prostatic urethral lift is being used as an alternative to other surgical interventions.

    CareFirst has adopted MCG criteria for clinical appropriateness.

    Patient selection: Patient has symptomatic BPH for which surgical intervention is indicated (e.g., symptoms refractory to medical therapy or otherwise requiring surgery).

    Policy expects PUL as an alternative to other surgical interventions; initial medical therapy is typical prior to considering surgical options.

    Anatomic/size criteria: Prostate size is appropriate for PUL treatment.prostate size <= 80 mL

    PUL is typically intended for prostates up to 80 mL; implantation usually uses 4–5 implants and does not preclude future prostate procedures.

    Use of the prostatic urethral lift (UroLift®) for indications other than surgical treatment of benign prostatic hypertrophy is considered not medically necessary. Requests for the procedure when not performed as a surgical intervention for BPH do not meet the coverage criteria.

    Prostatic urethral lift (UroLift®) is not medically necessary when used for any indication other than as a surgical alternative for benign prostatic hypertrophy. Coverage is limited to situations where surgical intervention for BPH is indicated and PUL is being used as an alternative to other surgical interventions.

    Coding and Definitions

    Prostate size
    Prostate size limitUp to 80 mL
    Typical number of implantsTypically 4–5 implants, depending on prostate size and shape
    Indication contextIntended for men with BPH refractory to medical therapy and inappropriate candidates for other established prostate surgeries
    Prostatic urethral lift (PUL, UroLift®) — definition
    Procedure nameProstatic urethral lift (PUL, UroLift®)
    MechanismMinimally invasive system deploying nonabsorbable monofilament implants to retract lateral prostatic lobes and open the urethral lumen
    Device componentsDelivery system and nonabsorbable monofilament suture that self-adjusts, tensions, and is trimmed after deployment
    Treatment effectRelieves or reduces urinary outflow obstruction due to BPH and does not preclude future prostate procedures

    Provider Actions and Administrative Requirements

    Prior Authorization

    Prior Authorization Required

    Prior authorization may be required. Providers must verify member benefits and obtain preauthorization when indicated prior to scheduling the procedure to avoid claim denials.

    • Submit preauthorization requests online at www.provider.carefirst.com or call 1-866-773-2884 (1-866-PRE-AUTH).
    • Check the member's contract for specific benefit limits, exclusions, and site-of-service requirements.
    Note

    Treatment Pathway Context

    The policy supports use of the prostatic urethral lift (PUL / UroLift®) when surgical intervention is indicated for benign prostatic hypertrophy and as an alternative to other surgical interventions. Use is intended for relief of urinary outflow obstruction due to BPH in patients appropriate for this minimally invasive surgical option.

    • PUL is an alternative to established prostate surgeries for eligible patients and does not preclude future prostate procedures if needed.
    Denial Risk

    Denial for Unsupported Indications

    Requests for PUL for indications not supported by the policy will be considered not medically necessary and are subject to denial. Ensure documentation demonstrates that the procedure is being requested as a surgical alternative for BPH when medical therapy is inadequate and that the patient's clinical characteristics meet coverage expectations.

    • PUL (UroLift®) is considered not medically necessary for all indications other than when surgical intervention is indicated for BPH.
    • Include clinical records showing prior medical therapy and rationale for surgical intervention to support medical necessity.

    Background

    Benign prostatic hypertrophy (BPH) is common in older men and is typically managed initially with medical therapy. A substantial subset of affected men eventually require surgical intervention, at which point the prostatic urethral lift (UroLift®) may be considered as a minimally invasive surgical alternative.

    Policy Summary
    PayerCareFirst
    PolicyProstatic Urethral Lift (UroLift®) for Benign Prostatic Hypertrophy
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateOct 1, 2025
    Last ReviewMay 14, 2025
    Next Review DateMay 14, 2025
    Key ActionSubmit preauthorization requests online or by phone and verify member contract benefits before performing the procedure.
    SourceLink
    On This Page
    Coverage CriteriaCoding and DefinitionsProvider Actions and Administrative RequirementsBackground