CurrentPremera BluecrossPolicy 7.01.598

MEDICAL POLICY - 7.01.598 Prostatic Urethral Lift

Defines medical necessity criteria, documentation, and coding for the prostatic urethral lift procedure to treat lower urinary tract obstruction due to benign prostatic hyperplasia (BPH). Applies to Premera commercial lines (not Medicare Advantage) for dates of service on or after the effective date.

Policy Summary

PayerPremera Bluecross

PolicyMEDICAL POLICY - 7.01.598 Prostatic Urethral Lift

Policy CodePolicy 7.01.598

Change TypeRevised (literature review/interim review)

Effective DateNov. 1, 2025

Next Review Date

Key ActionPatient medical records must document that all medical necessity criteria are met, including history/physical, documentation of prior medical therapy and duration (or intolerance), absence of prostate cancer, absence of obstructive median lobe, and prostate gland size and anatomy (chart notes or imaging).

SourceLink

POLICY UPDATE CHANGES

Policy updated with literature review through July 15, 2025; interim review approved October 13, 2025; policy statements unchanged.

New policy approved June 10, 2025 with literature review through June 14, 2024; effective dates of service on or after October 3, 2025 following 90-day provider notification.

<=80 mLProstate volume limit (mL)

6 monthsMinimum trial of medical therapy

InvestigationalRepeat procedure status

Coverage Summary

This policy applies to Premera commercial lines for dates of service on or after the effective date Nov. 1, 2025 (policy last revised Oct. 13, 2025). The coverage stance is mixed: PUL is covered when the medical necessity criteria are met; other uses, including repeat PUL, are considered investigational. The policy framework and effective dates reflect the documented policy history and interim review notes.

Key thresholds and quick facts

Prostate gland volume<= 80 mL

Minimum trial of medical therapy>= 6 months (or unable to tolerate therapy)

Repeat procedure statusRepeat PUL considered investigational

Medicare NCD statusNo NCD

Medical Necessity and Exclusions

Medical Necessity - Prostatic Urethral Lift

The Prostatic Urethral Lift procedure may be considered medically necessary when ALL of the following criteria are met:

Trial of medical therapy: The individual has persistent or progressive lower urinary tract symptoms despite medical therapy over a trial period of no less than 6 months, or is unable to tolerate medical therapy (medical therapy includes α1-adrenergic antagonists, 5α-reductase inhibitors, or combination therapy).>= 6 months (unless intolerant)
See policy for examples of medical therapy.
Prostate volume: Prostate gland volume is less than or equal to 80 mL.<= 80 mL
Chart documentation or imaging required.
Prostate anatomy demonstrates normal bladder neck without an obstructive or protruding median (middle) lobe.

Not Medically Necessary

Use of the prostatic urethral lift procedure when the above criteria are not met is considered not medically necessary.

Not Medically Necessary: Any single required criterion from the Medical Necessity tree is not met (e.g., prostate volume > 80 mL, presence of obstructive/protruding median lobe, urinary retention due to other causes, prostate cancer, or inadequate trial of or intolerance to medical therapy).

Failure to meet any one criterion renders PUL not medically necessary.

Investigational / Unproven

Other situations where PUL is considered investigational:

Investigational / Unproven: Use of the prostatic urethral lift procedure in all other situations, including repeat procedures (repeat PUL), is considered investigational.

Evidence on repeat PUL and definitions of retreatment are limited; reintervention rates reported but insufficient to demonstrate net health benefit.

CPT / HCPCS Codes

Primary CPT codes (covered when medically necessary)CPTCovered

52441	Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single implant.
52442	Each additional permanent adjustable transprostatic implant (List separately in addition to code for primary procedure).

HCPCS codes (covered when medically necessary)HCPCSCovered

C9739	Cystourethroscopy, with insertion of transprostatic implant; 1 to 3 implants.
C9740	Cystourethroscopy, with insertion of transprostatic implant; 4 or more implants.

Provider Actions & Billing Guidance

Documentation Required

Document medical necessity criteria

Summarize and submit documentation showing the individual meets the medical necessity criteria for PUL. Recommended documentation includes: history and physical exam with presenting lower urinary tract symptom severity (e.g., AUASI/IPSS or equivalent), documentation of prior medical therapy for BPH including agents used and duration (or documentation of intolerance/contraindication to medical therapy), absence of prostate cancer, evaluation excluding other causes of urinary retention (e.g., UTI, recent prostatitis, neurologic causes), and prostate anatomy and size showing gland volume ≤ 80 mL and no obstructive/protruding median lobe. Chart notes or imaging reports (e.g., transrectal ultrasound, MRI, cystoscopy) that document prostate size and anatomy should be included in the record submitted for review.

Office visit notes with history and physical and symptom scores (AUASI/IPSS) or equivalent
Medication history documenting ≥ 6 months of appropriate medical therapy (α‑blocker, 5α‑reductase inhibitor, or combination) or documented intolerance/contraindication
Documentation excluding prostate cancer (problem list, pathology, or diagnostic evaluation)
Chart notes or imaging (TRUS, MRI, cystoscopy) showing prostate gland size (≤ 80 mL) and absence of obstructive/protruding median lobe
Notes excluding other causes of urinary retention (recent UTI, prostatitis within past year, neurologic causes)

Background & Evidence Summary

The prostatic urethral lift (PUL, e.g., UroLift) places implants to retract prostate tissue and open the prostatic urethra, with the intended benefit of relieving urethral obstruction while preserving sexual (erectile and ejaculatory) function. Evidence supporting PUL includes randomized controlled trials (notably the LIFT and BPH6 trials), systematic reviews and meta-analyses, and real-world clinical experience. Trial populations and guideline statements generally selected patients with prostate volume up to 80 mL (30–80 mL in some guidance) and excluded those with an obstructive or protruding median (middle) lobe; these selection parameters are reflected in the medical necessity criteria. Data on repeat procedures are limited and heterogeneous: the LIFT 5‑year reintervention rate was reported as 13.6%, meta-analyses suggest approximately 6% per year, and real-world 1- and 2-year retreatment rates were reported at about 5.2% and 11.9%, respectively; consensus definitions of retreatment/reintervention are lacking, and evidence is insufficient to establish net health benefit for repeat PUL.

Study/Metric	Key findings
BPH6 RCT	PUL noninferior to TURP on composite endpoint; TURP superior for symptom control; PUL preserves ejaculatory function.
LIFT RCT	PUL superior to sham at 3 months for symptom improvement; long-term maintained benefits in subsets but with loss to follow-up.
Reintervention rate	LIFT 5-year reintervention 13.6%; meta-analysis ≈6% per year; real-world 1- and 2-year retreatment 5.2% and 11.9% respectively.

Definitions

PUL (Prostatic urethral lift)Minimally invasive procedure placing implants to retract prostate tissue and open the prostatic urethra (e.g., UroLift)

Medical therapy (for BPH)Therapies including α1-adrenergic blockers, 5α-reductase inhibitors, or combination therapy; may include antimuscarinics and PDE-5 inhibitors as clinically appropriate

Medicare Determinations

Determination	Number/Type	Effective date
National coverage determination for prostatic urethral lift		none

Revision History

2025-06-10policy_approval

New policy approved June 10, 2025 with literature review through June 14, 2024; effective for dates of service on or after October 3, 2025 following 90-day provider notification.

2025-10-13interim_reviewLatest

Interim review approved October 13, 2025; policy updated with literature review through July 15, 2025. Policy statements unchanged; effective date of the policy is November 1, 2025.