ModifiedColorado Rocky Mountain Health PlansPolicy MMP075.12

Prostate Services and Procedures and Impotence Treatment

Medicare-focused policy describing coverage guidance and related coding for prostate procedures (e.g., temporary prostatic stent, prostatic urethral lift, prostate artery embolization, HIFU/cryoablation) and impotence-related prosthetics/devices for members covered by Colorado Rocky Mountain Health Plans.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyProstate Services and Procedures and Impotence Treatment

Policy CodePolicy MMP075.12

Change TypeContent clarifications, added PAE harms and adverse events, and removed CPT 55874

Effective DateDec 1, 2025

Next Review DateN/A

Key ActionRefer to the related UnitedHealthcare Commercial Medical Policy titled Prostate Surgeries and Interventions for coverage guidance and prior authorization requirements.

SourceLink

POLICY UPDATE CHANGES

Revised language to indicate Medicare does not have an NCD for prostatic urethral lift (PUL) and LCDs/LCAs do not exist; refer to UnitedHealthcare Commercial Medical Policy titled Prostate Surgeries and Interventions for coverage guidelines.

Added language noting that untreated bladder outlet obstruction (BOO) can lead to urinary dysfunction, acute urinary retention (AUR), or kidney injury when discussing PAE.

Updated examples of adverse events for PAE to include urinary frequency, dysuria, hematospermia, and diarrhea.

Removed CPT code 55874 from Applicable Codes.

Removed content/language addressing prostate rectal spacers.

12/01/2025policy effective date

NCD 20.28Medicare NCD referenced

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

procedure codes listed

2commercial cross-references

Coverage Criteria and Rationale

Medicare NCD/LCD status and referral

Coverage guidance summary and cross-references

Medicare NCD/LCD status for listed procedures: Medicare does not have specific NCDs for temporary prostatic stents, prostatic urethral lift (PUL), nerve graft to restore erectile function during radical prostatectomy, high intensity focused ultrasound (HIFU), or cryoablation; for prostate artery embolization (PAE) Medicare has a general NCD for Therapeutic Embolization (20.28).

For coverage guidelines, refer to the UnitedHealthcare Commercial Medical Policy titled Prostate Surgeries and Interventions for temporary prostatic stent and PUL; refer to the UnitedHealthcare Commercial Medical Policy titled Nerve Graft to Restore Erectile Function During Radical Prostatectomy for nerve graft; and refer to InterQual CP: Procedures, High-Intensity Focused Ultrasound (HIFU) for HIFU/cryotherapy guidance.

PAE coverage rationale

Rationale for using commercial criteria to supplement Medicare NCD for PAE

Use of commercial criteria for PAE: UnitedHealthcare uses Commercial Medical Policy criteria to supplement the general NCD for Therapeutic Embolization (20.28) to determine when PAE is reasonable and necessary to treat BPH-related lower urinary tract symptoms (LUTS).

The supplemental criteria aim to (1) ensure consistent review to reduce inappropriate denials and inappropriate approvals, (2) help ensure patients receive appropriate surgical procedures for the requested indication, and (3) balance potential benefits (decreased inappropriate approvals and improved matching of therapy to indication) against potential harms (risk of inappropriate denial and associated clinical consequences).

The policy history notes that content and language addressing prostate rectal spacers were removed from the Coverage Rationale. This change is recorded in the 12/01/2025 revision summary and indicates that any prior references to prostate rectal spacers have been excised from the policy rationale.

A duplicate inventory item documents the same revision: language addressing prostate rectal spacers was removed from the Coverage Rationale. This mirrors the Policy History/Revision Information entry for 12/01/2025.

The list of procedure and diagnosis codes is provided for reference only. Listing a code in this policy does not imply that the service described by the code is a covered health service; benefit coverage is determined by the member-specific benefit plan document and applicable laws. Inclusion of a code does not guarantee reimbursement or claim payment.

The policy clarifies Medicare coverage status for prostatic urethral lift (PUL): Medicare does not have a National Coverage Determination (NCD) for PUL, and Local Coverage Determinations (LCDs)/Local Coverage Articles (LCAs) do not exist. For coverage guidelines, providers should refer to the UnitedHealthcare Commercial Medical Policy titled "Prostate Surgeries and Interventions."

Applicable Codes and Coding Notes

Applicable CPT Codes (examples)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 permanent adjustable transprostatic implant (List separately in addition to code for primary procedure)
55899	Unlisted procedure, male genital system
64999	Unlisted procedure, nervous system

Procedure CPT for PAECPT

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)

HCPCSHCPCS

L8699

Prosthetic implant, not otherwise specified

Removed CPT CodesCPTNot Covered

55874

CPT code 55874 (removed)

Provider Requirements, Prior Authorization, and Billing Guidance

Note

Coverage Guidance and Code Reference

Refer to related UnitedHealthcare commercial policies for coverage guidance and coding references. For Temporary Prostatic Stent, Prostatic Urethral Lift (PUL), HIFU, and cryoablation, see the UnitedHealthcare Commercial Medical Policy titled Prostate Surgeries and Interventions and the InterQual® CP: Procedures, High-Intensity Focused Ultrasound (HIFU) as applicable. Inclusion of codes in this policy is for reference only and does not guarantee coverage; benefit determination is based on the member's specific plan and applicable laws.

See UnitedHealthcare Commercial Medical Policy: Prostate Surgeries and Interventions for Temporary Prostatic Stent and PUL coverage guidelines.
See InterQual® CP: Procedures, High-Intensity Focused Ultrasound (HIFU) for HIFU and cryoablation guidance.
Code listings are reference-only and do not assure coverage or payment.

Prior Authorization

Delegate Prior Authorization

For Medicare Advantage members where a delegate (e.g., delegated vendor or entity) manages utilization management and prior authorization, providers must follow the delegate's prior authorization and utilization management requirements in addition to UnitedHealthcare policy directions.

Clinical Background

Benign prostatic hyperplasia (BPH) commonly produces lower urinary tract symptoms (LUTS) such as urinary frequency, urgency, weak stream, and nocturia. When obstruction of bladder outflow is present and left untreated, it can progress to bladder outlet obstruction (BOO), leading to clinical consequences including urinary dysfunction, acute urinary retention (AUR), and potential kidney injury. These sequelae are important considerations when evaluating procedural options for symptomatic BPH.

Definitions and Procedure Summaries

inv-21: Prostate Artery Embolization (PAE)

ProcedureProstate Artery Embolization (PAE): vascular embolization or occlusion procedure billed with CPT 37243 (includes radiological supervision/interpretation, intraprocedural road mapping, and imaging guidance)

Medicare NCDMedicare has a general National Coverage Determination for Therapeutic Embolization (NCD 20.28)

Use of Commercial CriteriaUnitedHealthcare uses Commercial Medical Policy criteria to supplement the general NCD (20.28) to determine when PAE is reasonable and necessary for BPH-related LUTS

Potential harms if inappropriatePolicy notes risks of inappropriate approvals/denials for PAE including post-embolization syndrome and other adverse events (e.g., urinary frequency, dysuria, hematospermia, diarrhea)

Related guidanceRefer to UnitedHealthcare Commercial Medical Policy titled 'Prostate Surgeries and Interventions' for detailed coverage guidelines

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyProstate Services and Procedures and Impotence Treatment

Policy CodePolicy MMP075.12

Change TypeContent clarifications, added PAE harms and adverse events, and removed CPT 55874

Effective DateDec 1, 2025

Next Review DateN/A

Key ActionRefer to the related UnitedHealthcare Commercial Medical Policy titled Prostate Surgeries and Interventions for coverage guidance and prior authorization requirements.

SourceLink

On This Page

When a delegate manages prior authorization for a member, follow the delegate's submission, documentation, and approval processes.
Contact the delegate or refer to delegate-specific portals for authorization status and requirements.

Denial Risk

PAE Coverage Inconsistency Risk

Prostate artery embolization (PAE) coverage decisions should be informed by the referenced UnitedHealthcare commercial criteria to reduce inappropriate denials or approvals. There is a risk that PAE requests may be denied if not reasonable and necessary; conversely, inappropriate approvals can expose members to unnecessary adverse events. Use the referenced criteria to balance access and patient safety.

PAE may be denied when documentation does not support medical necessity — inappropriate denials can lead to progression of BPH complications (e.g., acute urinary retention, bladder dysfunction, kidney injury).
Inappropriate approvals of PAE may expose members to procedure-related harms (e.g., bleeding, infection, post-embolization syndrome).
Applying consistent commercial criteria aims to minimize both types of errors and protect patient outcomes.

Billing Rule

Coding and Benefit Note

The following coding and benefit notes are provided for reference. Listing of codes does not imply coverage or reimbursement. Confirm benefit coverage against the member's specific plan document and applicable laws.

Temporary Prostatic Stent: CPT 53855 (Insertion of a temporary prostatic urethral stent).
Prostatic Urethral Lift (PUL): CPT 52441, 52442; HCPCS L8699 (prosthetic implant, not otherwise specified).
Unlisted codes that may be referenced: CPT 55899, 64999.
Inclusion of a code in this list is for reference only and does not guarantee coverage or payment.

Documentation Required

Records Retention

Providers must retain or have access to documentation supporting coverage decisions and be prepared to provide documentation upon request. This includes clinical records, prior authorization documentation, operative reports, imaging, and any records used to justify medical necessity.

Retain documentation consistent with payer and regulatory requirements; failure to produce documentation may affect coverage determinations.
Documentation should substantiate the indications, prior treatments tried, diagnostic findings, and rationale for the requested procedure.

Billing Rule

Claims Accuracy and Provider Responsibility

Providers are responsible for accurate claims submission using CPT®, CMS, and other coding guidelines. References to coding systems are definitional and do not guarantee payment; confirm payment and coverage per the member-specific benefit plan.

Submit claims with correct codes, modifiers, and documentation to support the billed services.
Ensure claims reflect the actual services provided and align with authorization documentation when applicable.

inv-22: Prostatic Urethral Lift (PUL)

ProcedureProstatic Urethral Lift (PUL) — minimally invasive implant procedure (examples: UroLift® System); implant billed using HCPCS L8699 and procedure CPTs 52441/52442

Medicare NCD statusMedicare does not have a National Coverage Determination (NCD) for PUL; Local Coverage Determinations (LCDs)/Local Coverage Articles (LCAs) do not exist

Coverage guidanceFor coverage guidelines, providers should refer to the UnitedHealthcare Commercial Medical Policy titled 'Prostate Surgeries and Interventions'

Heading change notePolicy heading modified from 'UroLift® System' to 'Prostatic Urethral Lift (PUL) (e.g., UroLift® System)' in the 12/01/2025 revision

inv-23: Therapeutic Embolization

DefinitionTherapeutic Embolization: referenced National Coverage Determination (NCD 20.28)

Relation to PAEMedicare's general NCD for Therapeutic Embolization (20.28) is cited in the policy as the applicable Medicare coverage framework for embolization procedures such as PAE

Policy revisionPolicy language was revised to state Medicare has a general NCD for Therapeutic Embolization (NCD 20.28)