These Clinical Review Criteria are provided for internal use by Kaiser Foundation Health Plan of Washington and its providers and are intended to assist in administering plan benefits; they do not constitute medical advice or guarantee coverage. Use of Kaiser Permanente names, logos, or marks for marketing or publicity is strictly prohibited. Always consult the member’s Evidence of Coverage or contact Kaiser Permanente Member Services at 1-888-901-4636 (TTY 711) to determine coverage for a specific service. When Medicare (CMS) coverage guidance is available, it takes precedence for Medicare members; for Non‑Medicare Members the document identifies new and emerging medical technologies that are considered to have unproven benefit because current evidence is insufficient to establish impact on health outcomes.

The excerpted sections list procedure names and CPT codes (for example: 51721, 52284, 53451–53454, 53865–53866, 55713–55714, 55881–55882) associated with urology procedures and related technologies. The text in these chunks presents a code inventory and brief procedure descriptors but does not include explicit coverage determinations, medical necessity criteria, or statements that the listed procedures are covered or not covered.

Portions of the excerpt function primarily as a listing of procedures and CPT codes categorized under the New and Emerging Medical Technologies and Procedures section for Non‑Medicare Members. Entries include, among others, codes for periurethral adjustable balloon continence devices, cystourethroscopy with drug‑coated balloon, in‑bore CT/MRI prostate biopsy, and transurethral thermal ultrasound ablation. The excerpt does not include accompanying coverage rules or medical necessity logic for these items.

This segment contains code listings and short procedure descriptors but does not state explicit exclusions. It therefore cannot be read as a complete exclusion list; rather, it enumerates items under consideration as new and emerging technologies without prescribing coverage status in this excerpt.

Several chunks repeat procedure and CPT code lines (for example, CPTs 53451–53454 for periurethral adjustable balloon devices; CPTs 53865–53866 for insertion/removal of temporary ischemic remodeling devices). These listings present codes only and do not include medical necessity rules, clinical criteria, or decision logic in the provided text.

The document repeats code listings across multiple fragments (e.g., the periurethral device and prostate biopsy/ablation codes) and does not include explicit coverage exclusions in these repetitions. The repeated lines should be interpreted as part of the policy’s code inventory in this excerpt rather than definitive coverage statements.

This segment lists additional procedure CPTs (including MR‑guided prostate ablation codes and intracranial LITT/coding that appear in the broader policy listing) but contains no explicit coverage decision language. The excerpt is limited to naming procedures and relevant CPT numbers without stating coverage status or required criteria.

The code listings and brief descriptors (such as CPTs 55713–55714 for in‑bore CT/MRI prostate biopsy and 55881–55882 for transurethral thermal ultrasound ablation) are presented without accompanying medical necessity statements in the excerpt. No determination of 'medically necessary' or 'not medically necessary' is included in these chunks.

Multiple fragments reiterate CPT procedure codes relevant to prostate procedures (biopsy, ischemic remodeling devices, thermal ultrasound ablation) for Non‑Medicare Members. The excerpt provides code references and short descriptors only and does not supply coverage criteria, clinical prerequisites, or exclusion language.

The listing in these chunks includes CPT codes and brief procedural descriptions but does not contain explicit statements declaring procedures to be covered or not covered. Providers should not infer coverage status from the code inventory shown here; the excerpt lacks the decision rules and criteria that would be present in the full policy.

A header in the source explicitly indicates applicability to Non‑Medicare Members. For non‑Medicare populations the document identifies technologies as 'new and emerging' and characterizes them as having unproven benefit when evidence is insufficient to establish impact on health outcomes. The excerpted code lists under this header do not include explicit exclusions or definitive coverage determinations.

The policy defines 'new and emerging medical technologies' as those considered to have unproven benefit when current scientific evidence is not yet sufficient to establish their impact on health outcomes. Kaiser Permanente Clinical Review Criteria are developed to assist in administering plan benefits but do not guarantee coverage; for any specific member, providers should verify benefits via the member’s Evidence of Coverage or by contacting Member Services.

Although many urology‑related CPTs appear in the excerpt (including codes for periurethral adjustable balloon devices, cystourethroscopy with drug‑coated balloon, ischemic remodeling device insertion/removal, in‑bore prostate biopsy, and transurethral thermal ultrasound ablation), the document does not include explicit 'not medically necessary' determinations for these items in the provided fragments. The only substantive stance shown for non‑Medicare members is that these technologies are considered new and emerging and may have unproven benefit due to insufficient evidence.

Because the excerpted sections function primarily as a code and procedure inventory without coverage rules, providers should verify prior authorization requirements and coverage with the payer. Kaiser Permanente’s Clinical Review Criteria may be referenced during prior authorization review, and member contract variability can affect coverage decisions—consult the member’s Evidence of Coverage or contact Member Services at 1-888-901-4636 (TTY 711).

For Non‑Medicare Members, the policy text in this excerpt identifies technologies considered to have unproven benefit because the evidence is insufficient to establish impact on health outcomes. The excerpt does not present accompanying medical necessity criteria or procedural eligibility requirements; those specifics are located elsewhere in the full policy.

No explicit 'not medically necessary' language appears in the provided fragments. Instead, the document flags the listed procedures as 'new and emerging' for non‑Medicare members and provides CPT code references and short descriptors without a definitive medical necessity determination in this excerpt.

The excerpt repeatedly lists CPT codes and brief descriptors but does not include coverage rules, exclusions, or 'not medically necessary' statements. Where the document notes technologies are 'new and emerging' for non‑Medicare members, it frames them as having unproven benefit rather than declaring them definitively not medically necessary within this excerpt.

Across the fragments provided, the content is a code inventory and short procedure descriptions only; there are no explicit statements in these chunks categorizing any listed procedure as 'not medically necessary.' The classification shown is that these technologies are considered new and emerging with unproven benefit for non‑Medicare members.

Several procedural codes that are not prostate specific (for example, intracranial LITT codes 61736/61737 and cranial neurostimulator CPTs 61889–61892) appear in the excerpt’s broader code listing; the presence of these codes in the document does not establish coverage policy for those procedures in the provided fragments, which lack explicit coverage determinations or exclusions.

The excerpted material does not present medical necessity criteria or exclusion rules for the listed procedures. It instead records the CPT codes and short descriptors for items identified as new and emerging technologies for non‑Medicare members; full coverage logic or criteria must be referenced in the complete policy.

Code listings for transurethral thermal ultrasound ablation (CPTs 55881, 55882), in‑bore prostate biopsy (55713, 55714), and temporary ischemic remodeling devices (53865, 53866) are shown repeatedly across chunks. These entries provide coding references and brief descriptions but do not provide accompanying medical necessity statements or explicit exclusions in the excerpted text.

The document’s fragments make clear these items are listed under the New and Emerging Medical Technologies and Procedures policy for Non‑Medicare Members. The excerpted code inventory does not include explicit determinations that any of the listed items are 'not medically necessary'—it instead indicates insufficient evidence to establish impact on health outcomes for the technologies so designated.

In summary, the provided excerpt is an itemized inventory of procedures and CPT codes organized under a 'For Non‑Medicare Members' heading and a brief policy framing that designates these as new and emerging technologies with unproven benefit where evidence is insufficient. This excerpt does not contain explicit coverage criteria, medical necessity rules, exclusions, or prior authorization requirements; providers should consult the full policy and verify member benefits and prior authorization needs with Kaiser Permanente.

Background: This document is a compilation of Kaiser Permanente Clinical Review Criteria covering new and emerging medical technologies and procedures. The criteria indicate that for Non‑Medicare Members the listed technologies are considered to have unproven benefit when evidence is insufficient, whereas for Medicare Members CMS coverage guidance takes precedence when available. The criteria are intended to assist plan benefit administration and are not clinical advice.

Policy dates: Last review: 2024-12-24. Next review: 2025-07-05. (Effective date not specified in the excerpt.)