ModifiedColorado Rocky Mountain Health PlansPolicy MMP075.13

Prostate Services and Procedures and Impotence Treatment

Medicare Advantage policy describing coverage guidance, coding references, and related commercial/Medicare guidance for prostate procedures and impotence-related prosthetics/devices affecting UnitedHealthcare Medicare Advantage members.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyProstate Services and Procedures and Impotence Treatment

Policy CodePolicy MMP075.13

Change TypeMaterial updates to PAE adverse events and referencesadded referral to Commercial policy for nerve graft criteria

Effective DateJun 1, 2026

Next Review Date

Key ActionRefer to the UnitedHealthcare Commercial Medical Policy titled Prostate Surgeries and Interventions for coverage criteria when Medicare guidance is absent.

SourceLink

POLICY UPDATE CHANGES

Added instruction to refer to the UnitedHealthcare Commercial Medical Policy titled Prostate Surgeries and Interventions for coverage criteria for nerve graft to restore erectile function.

Revised list of adverse events related to PAE: removed hematospermia; revised symptoms of post embolization syndrome to add fever.

Revised list of adverse events (removed hematospermia) and revised symptoms of post embolization syndrome (added fever).

Removed reference link to the UnitedHealthcare Commercial Medical Policy titled Nerve Graft to Restore Erectile Function During Radical Prostatectomy.

Archived previous policy version MMP075.12.

MMP075.13current policy identifier

5primary procedure/device topics

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Coverage and Determination Rules

Coverage when Medicare guidance absent

Covered when the referenced criteria are met or when an applicable Medicare NCD applies; when no Medicare NCD/LCD/LCA exists, UnitedHealthcare refers to specified commercial policies or InterQual for coverage guidance.

Reference-based coverage: If no Medicare NCD/LCD/LCA exists for a procedure (for example: temporary prostatic stent, prostatic urethral lift (PUL), nerve graft to restore erectile function during radical prostatectomy, or HIFU/cryoablation), refer to the UnitedHealthcare Commercial Medical Policy titled 'Prostate Surgeries and Interventions' (or InterQual CP for HIFU) to determine medical necessity; for prostate artery embolization (PAE), apply the Medicare NCD for Therapeutic Embolization (NCD 20.28) supplemented by the UnitedHealthcare Commercial criteria.

Do not rely on code listing alone; use the referenced policies (UnitedHealthcare Commercial Medical Policy or InterQual CP) and the Medicare NCD when present to determine medical necessity.

Where an applicable CMS NCD, LCD, or LCA exists for a procedure or service, follow the CMS determinations. For reference, the policy lists Medicare Administrative Contractors (MACs) and their jurisdictions (for example: Novitas Solutions, Inc.; Palmetto GBA; Noridian Healthcare Solutions, LLC; CGS Administrators, LLC; First Coast Service Options, Inc.; National Government Services, Inc.; Wisconsin Physicians Service Insurance Corporation). These MAC listings are provided to help locate regional LCD/LCA guidance but do not replace CMS NCD/LCD/LCA determinations.

Benefit coverage for any health service is determined by the member-specific benefit plan document, which identifies services that are covered, excluded, or subject to limitations. Listing a procedure code in this policy is for reference only and does not guarantee that the service is a covered benefit; in the event of a conflict between this policy and the member-specific benefit plan, the member-specific benefit plan supersedes this policy. For questions about a particular member’s coverage, contact the customer service number on the back of the member ID card or refer to the Administrative Guide.

A listing of a procedure or diagnosis code in this policy does not by itself indicate that the service described by the code is covered. The inclusion of a code is for reference and does not confer any right to reimbursement or guarantee claim payment. Coverage determinations must be made based on the member-specific benefit plan document and applicable laws.

Procedure and Billing Codes

Referenced CPT Codes (temporary stent, PUL, nerve graft)CPT

53855	Insertion of a temporary prostatic urethral stent, including urethral measurement
52441	Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single implant
52442	Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; each additional implant
55899	Unlisted procedure, male genital system
64999	Unlisted procedure, nervous system

PAE CPT CodeCPTCovered

37243

Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation... when performed on prostate tissue

PUL HCPCS CodeHCPCS

L8699

Prosthetic implant, not otherwise specified

HIFU/Cryo codingCPT

55899

Unlisted procedure, male genital system (used for HIFU/cryoablation)

Provider Responsibilities, Prior Authorization, and Claims

Prior Authorization

Provider Responsibilities and Prior Authorization

The following guidance summarizes provider responsibilities related to prior authorization, documentation, and claims for Medicare Advantage members. Providers must follow member-specific benefit plans and applicable laws; when a delegate manages utilization management or prior authorization for a UnitedHealthcare Medicare Advantage member, providers must follow the delegate's prior authorization requirements.

Providers are expected to retain or have access to appropriate documentation to support coverage determinations when requested.
Providers are responsible for submission of accurate claims using CPT®, CMS, or other coding guidelines; references to codes are definitional and do not guarantee reimbursement.
When a delegate manages utilization management and prior authorization for a Medicare Advantage member, providers must follow the delegate's requirements in addition to UnitedHealthcare policies.
UnitedHealthcare follows Medicare statutes, NCDs, LCDs, and manuals where applicable; in the absence of specific Medicare criteria, internal coverage criteria referenced in this policy may be applied.
Incorrect application of supplemental or internal criteria (including PAE-specific criteria used to supplement Medicare guidance) may lead to inappropriate denials or approvals; providers should ensure documentation supports the clinical indications used for prior authorization decisions.

Clinical Background

Benign prostatic hyperplasia (BPH) can cause lower urinary tract symptoms (LUTS), bladder outlet obstruction, acute urinary retention, and potential kidney injury if left untreated. Procedural options addressed in this policy include prostate artery embolization (PAE), prostatic urethral lift (PUL), temporary prostatic stents, nerve grafting during radical prostatectomy, high-intensity focused ultrasound (HIFU), and cryoablation. This Medicare Advantage policy is intended to support coverage determinations for UnitedHealthcare Medicare Advantage members and to be used with applicable CMS guidance, member-specific benefit documents, and referenced UnitedHealthcare commercial policies where Medicare guidance is absent.

Procedure and Policy Definitions

Prostate Artery Embolization (PAE) — definition

TermProstate Artery Embolization (PAE)

DefinitionVascular embolization or occlusion procedure for prostate tissue (CPT 37243).

CPT code37243

ScopeUsed for BPH-related lower urinary tract symptoms (LUTS) when clinically indicated.

IncludesRadiological supervision and interpretation, intraprocedural road mapping, and imaging guidance necessary to complete the intervention.

Prostatic Urethral Lift (PUL) implant — definition

Term