CurrentMass General Brigham Health PlanPolicy N/A

Prostatic urethral lift (PUL / UroLift) — Coverage Criteria

Defines Mass General Brigham Health Plan medical necessity, coverage criteria, exclusions, coding information, and payer-specific variations for prostatic urethral lift (UroLift) for treatment of BPH-related lower urinary tract symptoms.

Policy Summary

PayerMass General Brigham Health Plan

PolicyProstatic urethral lift (PUL / UroLift) — Coverage Criteria

Policy CodePolicy N/A

Change TypeClinical criteria revised

Effective DateN/A

Next Review DateN/A

Key ActionConfirm documentation shows AUA score >7, prior medical therapy trial (alpha-blocker ≥3 months or 5‑ARI ≥6 months) and prostate volume <100 cc before requesting coverage.

SourceLink

POLICY UPDATE CHANGES

Prostate gland volume criterion changed from <80 to <100 cc.

Prior authorization status was updated (taken off prior authorization in Dec 2024) and prior authorization table updated in Jan 2026.

MassHealth and OneCare/SCO variation language added to describe use of external guidance for those plan types.

AUA >7Symptom threshold

<100 ccMax prostate volume

α-blocker ≥3 moMedication trial

52441–52442; C9739–C9740Procedure codes

Policy Summary

PayerMass General Brigham Health Plan

PolicyProstatic urethral lift (PUL / UroLift) — Coverage Criteria

Policy CodePolicy N/A

Change TypeClinical criteria revised

Effective DateN/A

Next Review DateN/A

Key ActionConfirm documentation shows AUA score >7, prior medical therapy trial (alpha-blocker ≥3 months or 5‑ARI ≥6 months) and prostate volume <100 cc before requesting coverage.

SourceLink

On This Page

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Coverage Criteria for Prostatic Urethral Lift (PUL/UroLift)

Initial coverage criteria

Covered when ALL of the following are met:

Overall coverage conditions: Member has moderate-to-severe lower urinary tract obstruction (AUA symptom score >7) due to benign prostatic hyperplasia (BPH) and all criteria below are met

Diagnosis and anatomy: The member has a diagnosis of BPH, and symptoms are caused by enlargement of the median and/or lateral prostate lobes

Anatomic exclusion: Prostate anatomy demonstrates bladder neck without evidence of a stricture

Prior medical therapy or intolerance: Member has persistent or progressive lower urinary tract symptoms despite medical therapy (alpha-adrenergic antagonists ≥3 months, or 5‑alpha‑reductase inhibitors ≥6 months, or maximally titrated combination therapy), OR is unable to tolerate medical therapy

Either a documented trial of therapy (with durations above) or documented intolerance satisfies this criterion

Size: Prostate gland volume is <100 cc<100 cc

Coverage is conditional on the absence of any listed exclusion. Relevant qualifying conditions include: contact dermatitis with a nickel allergy; prostate‑specific antigen (PSA) ≥3 ng/mL without appropriate evaluation to exclude prostate cancer; a recent urinary tract infection or prostatitis; or any urethral condition that may prevent insertion of the device delivery system into the bladder. Providers should document the presence or exclusion of these conditions in the clinical record when submitting requests.

Any request that meets one of the explicit exclusions is not eligible for coverage and may be denied. Examples that will trigger non‑coverage include documented nickel contact dermatitis, elevated PSA without appropriate cancer‑exclusion testing, recent UTI/prostatitis, or anatomical findings preventing device insertion.

Procedure and Clinical Coding

Procedure codesmixed

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) Maximum 6 units.
C9739	Cystourethroscopy, with insertion of transprostatic implant; one to three implants.
C9740	Cystourethroscopy, with insertion of transprostatic implant; four or more implants.

AUA symptom score

AUA symptom score threshold>7 (American Urological Association [AUA] symptom score >7 required to meet 'moderate-to-severe' LUTS)

Clinical contextDefines 'moderate-to-severe' lower urinary tract obstruction due to BPH for coverage determination

Documentation expectationAUA score must be documented in clinical record to support coverage decision

Prostate gland volume

Maximum prostate gland volume<100 cc

Policy historyProstate gland volume criterion changed from <80 cc to <100 cc (March 2022 update)

Provider Actions, Authorization & Documentation

Prior Authorization

Prior Authorization Note — plan-specific variations

Prior authorization requirements vary by product line. Providers must obtain authorization when required for the member’s plan — see payer-specific prior authorization rules (Commercial, Qualified Health Plans, Mass General Brigham ACO, Medicare Advantage, OneCare, Senior Care Options). Verify member-specific prior authorization status before scheduling. Note: Policy history shows multiple prior-authorization table updates; always confirm current plan rules.

Step Therapy

Required medical therapy trial

Members must have tried and failed an adequate course of medical therapy prior to approval unless intolerant or therapy contraindicated. Adequate trial is defined as one of the following: an alpha-adrenergic antagonist for at least 3 months, OR a 5‑alpha‑reductase inhibitor for at least 6 months, OR combination medical therapy maximally titrated.

Definitions

Prostatic Urethral Lift (PUL/UroLift)

Procedure descriptionTransurethral, cystoscopically guided implant procedure that mechanically opens the prostatic urethra by placing implants which compress prostate tissue and increase the urethral lumen.

Approach/anesthesiaMinimally invasive, short endoscopic procedure; can be performed under local, regional, or general anesthesia.

Trade nameAlso referred to as UroLift (Prostatic Urethral Lift, PUL)

Benign Prostatic Hyperplasia (BPH)

DefinitionBenign prostatic hyperplasia (BPH): hyperplastic nodules in the periurethral or transitional zone of the prostate causing lower urinary tract symptoms; prevalence increases with age.

Epidemiology noteBPH prevalence >80% in individuals ages 70–79 (as noted in definition).

Background

Benign prostatic hyperplasia (BPH) causes lower urinary tract symptoms through enlargement of periurethral or transitional zone prostate tissue. The prostatic urethral lift is a transurethral implant procedure designed to mechanically open the prostatic urethra by placing implants that compress prostate tissue and increase urethral lumen; suitability for the procedure requires exclusion of the conditions listed above (for example, active infection or anatomical barriers to device placement).