CurrentColorado Rocky Mountain Health PlansPolicy MMP075.12

Prostate Services and Procedures and Impotence Treatment

Medicare Advantage policy describing Medicare-related coverage guidance, references, and applicable procedure/HCPCS/CPT codes for prostate-related interventions (temporary prostatic stents, prostatic urethral lift, nerve graft during radical prostatectomy, prostate artery embolization, HIFU/cryoablation) and impotence-related prosthetics/devices. It primarily references Commercial Medical Policies and Medicare NCDs/LCDs and provides coding lists and usage instructions.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyProstate Services and Procedures and Impotence Treatment

Policy CodePolicy MMP075.12

Change TypeRevisions, additions, and code removal

Effective DateDec 1, 2025

Next Review Date

Key ActionWhen Medicare NCD/LCD/LCA does not exist for a procedure, providers should refer to the UnitedHealthcare Commercial Medical Policy referenced (e.g., Prostate Surgeries and Interventions, Nerve Graft policy) for coverage criteria and retain appropriate documentation to support coverage decisions.

POLICY UPDATE CHANGES

Coverage Rationale: removed content/language addressing prostate rectal spacers.

Prostatic Urethral Lift (PUL) heading modified and language revised to note Medicare does not have an NCD and LCDs/LCAs do not exist; refers to UnitedHealthcare Commercial Medical Policy.

Prostate Artery Embolization (PAE) section added language regarding complications from long-term untreated BPH, including acute urinary retention and kidney injury.

Replaced prior language to state simply that Medicare has a general NCD for Therapeutic Embolization (NCD 20.28).

Removed CPT code 55874 from Applicable Codes list.

Updated CMS Related Documents list to reflect current information; removed Clinical Evidence and FDA sections.

5Procedures referenced

1Medicare NCD referenced

Coverage Summary

This Medicare Advantage coverage criteria (Policy MMP075.12) is informational and describes Medicare-related guidance and referenced UnitedHealthcare commercial criteria for prostate services and impotence-related devices. Policy status: CURRENT. Effective date: 2025-12-01. Last review/committee approval date: 2025-11-12.

Policy Metadata

Policy NumberMMP075.12

Effective Date2025-12-01

Last Review2025-11-12

SubjectProstate services, procedures, and impotence treatment (Medicare Advantage policy)

Coverage Stanceinformational

Medicare Relationship & Referenced Commercial Criteria

General Medicare Coverage Relationship / Referenced Commercial Criteria

Policy indicates presence or absence of Medicare NCDs/LCDs and instructs use of referenced commercial criteria where Medicare guidance is absent:

General Medicare relationship: If a Medicare National Coverage Determination (NCD), Local Coverage Determination (LCD), or Local Coverage Article (LCA) exists for an item/service, follow that Medicare guidance.

Reference to commercial criteria when Medicare absent: If no Medicare NCD/LCD/LCA exists for an item/service, UnitedHealthcare refers to corresponding UnitedHealthcare Commercial Medical Policy criteria to supplement general Medicare criteria.

Providers must retain documentation to support coverage decisions.

Use of internal criteria: UnitedHealthcare applies internal coverage criteria in circumstances where Medicare guidance is absent or allows flexibility, based on clinical evidence and guidelines.

These internal criteria are developed from clinical evidence and widely used treatment guidelines.

Procedure-specific Guidance

Checklist-style summary of procedure-level guidance: If a Medicare NCD, LCD, or LCA exists for an item/service, follow that Medicare guidance; if no Medicare determination exists, UnitedHealthcare refers to the corresponding UnitedHealthcare Commercial Medical Policy criteria. Temporary Prostatic Stent: Medicare has no NCD and no LCDs/LCAs; refer to the UnitedHealthcare Commercial Medical Policy titled Prostate Surgeries and Interventions. Prostatic Urethral Lift (PUL): Medicare has no NCD and no LCDs/LCAs; refer to the UnitedHealthcare Commercial Medical Policy titled Prostate Surgeries and Interventions. Nerve Graft to Restore Erectile Function During Radical Prostatectomy: Medicare has no NCD and no LCDs/LCAs; refer to the UnitedHealthcare Commercial Medical Policy of the same name. Prostate Artery Embolization (PAE) for BPH-related LUTS: Medicare has a general NCD for Therapeutic Embolization (NCD 20.28) and no LCDs/LCAs; UnitedHealthcare supplements NCD 20.28 with Commercial criteria to determine when PAE is reasonable and necessary. High Intensity Focused Ultrasound (HIFU) and Cryoablation: Medicare has no NCD and no LCDs/LCAs; refer to InterQual CP: Procedures, High-Intensity Focused Ultrasound (HIFU).

Definitions

PAEProstate Artery Embolization for treatment of BPH-related lower urinary tract symptoms.

NCDNational Coverage Determination (Centers for Medicare & Medicaid Services).

LCD/LCALocal Coverage Determination / Local Coverage Article.

Coding

Temporary Prostatic Stent - CPTCPT

53855

Insertion of a temporary prostatic urethral stent, including urethral measurement

Prostatic Urethral Lift (PUL) - CPTCPT

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

Nerve Graft to Restore Erectile Function During Radical Prostatectomy - CPT (unlisted)CPT

55899	Unlisted procedure, male genital system
64999	Unlisted procedure, nervous system

Prostate Artery Embolization (PAE) - CPTCPT

37243

Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural road mapping, and imaging guidance necessary to complete the intervention: for tumors, organ ischemia, or infarction (when performed on prostate tissue)

Prostatic Urethral Lift - HCPCSHCPCS

L8699

Prosthetic implant, not otherwise specified

Removed/Previously Listed CodesCPT

55874

Removed from Applicable Codes list per 12/01/2025 revision

Provider Actions & Requirements

Documentation Required

Refer to Commercial Medical Policies when Medicare guidance absent

When Medicare NCD/LCD/LCA does not exist for a procedure, providers should refer to the UnitedHealthcare Commercial Medical Policy referenced (for example, Prostate Surgeries and Interventions or the relevant Commercial policy) for coverage criteria and retain appropriate documentation to support coverage decisions.

Related Commercial Medical Policy: Prostate Surgeries and Interventions
Related Commercial Medical Policy: Nerve Graft to Restore Erectile Function During Radical Prostatectomy

Documentation Required

Follow Medicare source materials where applicable

Providers must follow existing Medicare statutes, regulations, National Coverage Determinations (NCDs), and Local Coverage Determinations/Articles (LCDs/LCAs) when present; this policy does not supersede Medicare source materials. Where Medicare guidance exists, follow that Medicare guidance and retain documentation to support coverage.

Background & Evidence

Background: Medicare Advantage policies are used to support UnitedHealthcare coverage decisions and are informational. Providers must follow Medicare statutes, regulations, NCDs, and LCDs when present; where Medicare guidance is absent or allows flexibility, UnitedHealthcare applies internal criteria developed from clinical evidence and referenced Commercial Medical Policies. Providers are expected to retain documentation to support coverage determinations and follow Medicare source materials when they exist.

Source	Detail
Society position statement	Society of Interventional Radiology position statement: prostate artery embolization for treatment of benign disease of the prostate (J Vasc Interv Radiol. 2014)
Literature reviews cited	Multiple reviews and articles (e.g., Moreira et al. 2017; StatPearls 2024; Sandhu & Cheung 2025)

Medicare Determinations

Name	Number	Type	Effective Date
Therapeutic Embolization	20.28	NCD

Revision History

12/01/2025revised (non-material)

Coverage Rationale: removed content/language addressing prostate rectal spacers.

12/01/2025revised (non-material)

Prostatic Urethral Lift (PUL) heading modified and language revised to note Medicare does not have an NCD and LCDs/LCAs do not exist; refers to UnitedHealthcare Commercial Medical Policy.

12/01/2025added (material)

Prostate Artery Embolization (PAE) section added language regarding complications from long-term untreated BPH, including acute urinary retention and kidney injury.

Definitions

Quick Definitions

PAEProstate Artery Embolization for treatment of BPH-related lower urinary tract symptoms.

NCDNational Coverage Determination (Centers for Medicare & Medicaid Services).

LCD/LCALocal Coverage Determination / Local Coverage Article.

Procedure statements: Temporary Prostatic Stent (e.g., Spanner, Memokath): Medicare does not have an NCD; LCDs/LCAs do not exist. Refer to UnitedHealthcare Commercial Medical Policy: Prostate Surgeries and Interventions.

CPT code example: 53855.

Procedure statements: Prostatic Urethral Lift (PUL) (e.g., UroLift System): Medicare does not have an NCD; LCDs/LCAs do not exist. Refer to UnitedHealthcare Commercial Medical Policy: Prostate Surgeries and Interventions.

CPT examples: 52441, 52442; HCPCS L8699.

Procedure statements: Nerve Graft to Restore Erectile Function During Radical Prostatectomy: Medicare does not have an NCD; LCDs/LCAs do not exist. Refer to UnitedHealthcare Commercial Medical Policy: Nerve Graft to Restore Erectile Function During Radical Prostatectomy.

CPT examples: 55899, 64999.

Procedure statements: Prostate Artery Embolization (PAE) for BPH-related LUTS: Medicare has a general NCD for Therapeutic Embolization (20.28). LCDs/LCAs do not exist. UnitedHealthcare uses Commercial criteria to supplement NCD 20.28 to determine when PAE is reasonable and necessary.

CPT example: 37243. Criteria supplement aims to ensure consistency and to balance risks/benefits; complications of untreated BPH and potential adverse events from PAE are considered.

Procedure statements: High Intensity Focused Ultrasound (HIFU) and Cryoablation of the Prostate: Medicare does not have an NCD; LCDs/LCAs do not exist. Refer to InterQual CP: Procedures, High-Intensity Focused Ultrasound (HIFU).

CPT/HCPCS references may include unlisted codes (e.g., 55899).