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    v1.0.28
    OpenPayerPolicy UpdatesUrologyselect_health UroLift Coverage & Prior Auth Update…
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    Currentselect_healthPolicy CCP.1529

    Prostatic urethral lift (UroLift) for benign prostatic hyperplasia

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    Defines coverage criteria, limitations, contraindications, and alternative services for UroLift (prostatic urethral lift) for treatment of lower urinary tract symptoms from benign prostatic hyperplasia for Select Health of South Carolina members.

    Policy Summary
    Payerselect_health
    PolicyProstatic urethral lift (UroLift) for benign prostatic hyperplasia
    Policy CodePolicy CCP.1529
    Change TypeRevised (2024, 2025)
    Effective DateAug 1, 2023
    Last ReviewAug 1, 2025
    Next Review DateDec 1, 202639d
    Key ActionObtain prior authorization to confirm prostate volume 30–80 cc and absence of an obstructive median lobe before proceeding.
    SourceLink
    POLICY UPDATE CHANGES

    In 2025, we updated the references and revised the medical necessity criteria to align with current American Urological Association guideline recommendations for prostatic urethral lift procedures, deleting the age criterion and the requirement of medication failure.

    In 2024, we revised the coverage section based on updated clinical guidelines from American Urological Association and reorganized findings, adding several systematic reviews.

    30–80 ccRoutine coverage volume
    81–100 ccCase-by-case volume
    >100 ccContraindicated volume

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    preserve sexual functionPreservation indication
    6.0%Annual reintervention

    Coverage Criteria for Prostatic Urethral Lift (UroLift)

    Medically necessary (covered) criteria

    Covered when ALL of the following are met

    Primary coverage criteria: Member has a prostate volume between 30 and 80 cc.30-80 cc

    Aligned with American Urological Association guideline recommendations and trial inclusion criteria.

    Primary coverage criteria: There is verified absence of an obstructive median lobe of the prostate.
    Patient preference: Patient desires preservation of erectile and ejaculatory function (when applicable).

    Case-by-case coverage

    Limited evidence / case-by-case consideration

    Case-by-case: Prostate volume greater than 80 cc and up to 100 cc OR presence of an obstructive median lobe may be considered on a case-by-case basis due to limited evidence of improved outcomes.81-100 cc or obstructive median lobe

    Provider should supply supporting clinical rationale and evidence; payor will review individually.

    Prostatic urethral lift (UroLift) is contraindicated for members with a prostate volume >100 cc. Other absolute contraindications include active urinary tract infection, urethral conditions that prevent insertion of the delivery system, urinary incontinence, current gross hematuria, and a known nickel allergy.

    Providers should confirm that members do not meet any of these contraindications before scheduling the procedure. Cases that fall outside routine eligibility (for example, prostate volume >100 cc) are not appropriate for UroLift and will be denied; documentation demonstrating absence of these contraindications is expected during prior authorization.

    For members with a prostate volume of 81–100 cc or with an obstructive median lobe, coverage is considered on a case-by-case basis because published evidence supporting improved outcomes in these populations is limited. The policy requires the provider to submit supporting clinical rationale and any pertinent evidence for individualized review.

    Systematic reviews and recent studies note that evidence for UroLift in larger prostates and obstructive median lobes is sparse. The MedLift prospective, nonrandomized study (n = 45) reported promising results for obstructive median lobes but was insufficient to establish safety and effectiveness for broad coverage. Providers should be aware that limited evidence may lead to denials absent compelling, case-specific justification.

    Key Coding & Prostate Volume Guidance

    Prostate volume thresholds — coverage
    Covered prostate volume30–80 cc
    Case-by-case prostate volume81–100 cc
    Contraindicated prostate volume>100 cc

    Provider Requirements, Prior Authorization, and Denial Risks

    Prior Authorization

    Prior authorization required to confirm prostate size and absence of median lobe

    Prior authorization is required to confirm the patient meets coverage criteria: prostate volume between 30 and 80 cc and verified absence of an obstructive median lobe. Cases with prostate volume 81–100 cc or an obstructive median lobe will be evaluated on a case-by-case basis during authorization review.

    Step Therapy

    No medication-failure requirement before UroLift

    A trial of medical therapy is not required before proceeding with UroLift; medical therapy may be discussed but failure of medications is not an absolute prerequisite for procedural intervention.

    Documentation Required

    Definitions and Device Background

    Prostatic urethral lift (UroLift) — description
    DefinitionAn endoscopic procedure that retracts obstructing prostatic lobes using small metal implants (a capsular nitinol tab and a urethral stainless steel tab connected by non-absorbable suture) to open the prostatic urethra.
    Implant detailsDelivered via a disposable cartridge; typically requires three to four implants per patient to create an open channel from bladder neck to verumontanum.
    Setting and anesthesiaPerformed under local or general anesthesia in inpatient or outpatient settings.
    Regulatory background — UroLift / UroLift System
    Initial FDA approval (UL400, 2013)Approved for treatment of BPH in patients age ≥50 with no obstructive median or lateral lobe hyperplasia and prostate volumes 30–80 cc.
    Expanded approvals (UL500, 2017)

    Clinical Background

    Benign prostatic hyperplasia (BPH) is a common cause of lower urinary tract symptoms in men. Management options range from watchful waiting for mild symptoms to medical therapy (including alpha blockers, 5-alpha reductase inhibitors, tadalafil, and antimuscarinics) and surgical or minimally invasive interventions for more significant obstruction or refractory symptoms.

    The prostatic urethral lift (UroLift) is a minimally invasive endoscopic procedure that uses small implants to retract obstructing prostatic lobes and open the prostatic urethra. It is typically performed in an outpatient setting using local or general anesthesia and generally involves placement of multiple implants to restore urinary flow. UroLift offers the potential advantage of preserving erectile and ejaculatory function compared with some alternative surgical treatments, but comparative effectiveness and long-term reintervention rates vary across studies.

    Policy Revision History

    2025material_revisionLatest

    Updated references and revised medical necessity criteria to align with current AUA guideline recommendations; removed the age criterion and eliminated the requirement for prior medication failure.

    2024material_revision

    Revised the coverage section based on updated AUA clinical guidelines, reorganized findings, and added several systematic reviews.

    Policy Summary
    Payerselect_health
    PolicyProstatic urethral lift (UroLift) for benign prostatic hyperplasia
    Policy CodePolicy CCP.1529
    Change TypeRevised (2024, 2025)
    Effective DateAug 1, 2023
    Last ReviewAug 1, 2025
    Next Review DateDec 1, 202639d
    Key ActionObtain prior authorization to confirm prostate volume 30–80 cc and absence of an obstructive median lobe before proceeding.
    SourceLink
    On This Page
    Coverage Criteria for Prostatic Urethral Lift (UroLift)Key Coding & Prostate Volume GuidanceProvider Requirements, Prior Authorization, and Denial RisksDefinitions and Device BackgroundClinical BackgroundPolicy Revision History

    Required clinical documentation for authorization

    Document and submit objective evidence showing measured prostate volume and confirmation there is no obstructive median lobe; include clinical rationale when case-by-case review is needed and note patient preference for preservation of erectile/ejaculatory function when relevant.

    • Prostate volume measurement (numeric value and measurement method/source).
    • Statement verifying absence of an obstructive median lobe (imaging or exam).
    • Clinical rationale and supporting evidence for cases with prostate volume 81–100 cc or obstructive median lobe.
    • Documentation of patient care goals (e.g., desire to preserve erectile/ejaculatory function) when applicable.
    Denial Risk

    Denial risks for out-of-criteria prostate size or anatomy

    Procedures for members with prostate volume >100 cc are contraindicated and will be denied; interventions for prostate volumes 81–100 cc or with an obstructive median lobe are subject to case-by-case review and may be denied due to limited supporting evidence.

    • Do not submit authorization requests for prostate volume >100 cc (contraindicated).
    • For 81–100 cc or obstructive median lobe, include robust supporting clinical rationale to reduce the risk of denial.
    2017 approval expanded to include lateral and median lobe prostate hyperplasia (UL500).
    Further model clearances (2019 onward)Subsequent clearances expanded indications to include some devices for prostates up to 100 cc and patients aged 45+ based on substantial equivalence and supporting data.