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.

ModifiedSelectHealthPolicy 672

Optilume urethral drug‑coated balloon (DCB) for urethral stricture — Coverage Criteria

Customize your policy alerts

Sign up for SelectHealth Policy 672 alerts

Get alerted when Policy 672 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Coverage criteria for Optilume urethral drug‑coated balloon for treatment of recurrent bulbar urethral strictures in SelectHealth members; includes related coverage positions for PTNS, pelvic vein procedures, penile implants, TLV, and other urologic interventions across Commercial, Medicare (CMS), and Community Care (Medicaid) products.

Policy Summary

PayerSelectHealth

PolicyOptilume urethral drug‑coated balloon (DCB) — Coverage Criteria

Policy CodePolicy 672

Change TypeMultiple material revisions to exclusions and PTNS treatment limits

Effective DateSep 26, 2023

Last ReviewOct 21, 2024

Next Review DateOct 21, 2024

Key ActionObtain prior authorization for CPT 52284 and document that the member is an adult male with a recurrent bulbar urethral stricture <3 cm and has required prior treatments.

SourceLink

POLICY UPDATE CHANGES

Revised exclusionary statement to state Select Health does not cover any repeat applications of Optilume due to insufficient data to support safety and efficacy.

Added exclusion that Optilume is not covered for treatment of other indications including but not limited to benign prostatic hyperplasia (BPH).

Modified criteria for Treatment Limitations: initial PTNS treatments are covered weekly for 12 weeks, then every one to two months for the remainder of one year; if the patient fails to improve after 6 PTNS treatments, continued treatment is not medically necessary; continued treatment after the initial 12 months is not covered unless it has been 24 months since completion and symptoms recur, in which case a new 12-week trial is required.

PTNS is contraindicated for patients with pacemakers or implantable defibrillators, those prone to excessive bleeding, with nerve damage affecting tibial or pelvic floor function, or who are pregnant or planning pregnancy during treatment.

Coverage of continued treatment after initial 12 months without defined waiting period was removed; now requires 24-month gap before retreatment unless new trial.

Added exclusion: Select Health does not cover BlueWind Revi, eCoin, Freedom, and other leadless neuromodulation systems due to safety concerns and lack of long-term outcomes.

Added exclusion: Select Health does not cover wearable neuromodulation systems (e.g., Vivally and ZIDA) as experimental/investigational.

For Commercial Plan Policy, modified requirements in criteria #B to include: '1 Meets one of the above criteria for surgery OR 2. Post-surgical (ligation) recurrence of varicoceles'.

≤3 cmMaximum stricture length

≥18Minimum age

52284Prior auth CPT

3 moConservative therapy prior

6 txPTNS failure threshold

12 wkPTNS initial course

Coverage Criteria and Limitations

Initial application — covered indications

Covered when ALL of the following are met

Optilume coverage criteria: 1) Member is >= 18 years of age; 2) Member has urinary symptoms associated with a urethral stricture; 3) Member has a urethral stricture < 3 cm in length; 4) Member has recurrent bulbar urethral strictures.

As stated in the Commercial Plan Policy.

Pelvic Congestion Syndrome - Coverage Criteria

Covered when ALL of the following are met

PCS criteria: A. Pelvic pain of at least six months duration without other etiology; B. Imaging consistent with pelvic venous changes; C. Tried and failed conservative therapy of at least 3 months duration, including prescription anti-inflammatories unless contraindicated.see individual nodes

Documentation must demonstrate all items

Policy Summary

PayerSelectHealth

PolicyOptilume urethral drug‑coated balloon (DCB) — Coverage Criteria

Policy CodePolicy 672

Change TypeMultiple material revisions to exclusions and PTNS treatment limits

Effective DateSep 26, 2023

Last ReviewOct 21, 2024

Next Review DateOct 21, 2024

Key ActionObtain prior authorization for CPT 52284 and document that the member is an adult male with a recurrent bulbar urethral stricture <3 cm and has required prior treatments.

SourceLink

On This Page

Pelvic/Labial Varicosities - Coverage Criteria

Covered when ALL of the following are met

Pelvic/Labial varicosities criteria: A. Patient is unable to perform activities of daily living such as feeding, bathing, dressing, grooming, meal preparation, house chores, and occupational tasks; B. Failed to respond to conservative therapy of at least 3 months duration, including prescription anti-inflammatories unless contraindicated; C. Varicose veins to be treated must be 4 mm or greater in diameter.see individual nodes

Documentation must demonstrate all items

Coverage criteria (Commercial & CHIP with rider)

Covered when ALL of the following are met (for plans that include sexual dysfunction rider):

Eligibility and prior treatments: Member's history and physical are consistent with sexual dysfunction; member has a medical (organic) condition directly contributing to erectile dysfunction; appropriate covered medical therapies have been tried and failed (e.g., testosterone replacement if appropriate, intracavernous alprostadil injections, suppositories, or PDE5 inhibitors).

Applies only to plans with a sexual dysfunction rider

Replacement of a penile implant is covered if the device malfunctions, breaks, or becomes infected, and medical necessity criteria continue to be met; replacement is not covered if it is part of the manufacturer's warranty.

Replacement requires continued meeting of initial medical necessity criteria

Not Medically Necessary / Investigational

SelectHealth Commercial Plan

Commercial exclusion: Percutaneous renal nerve ablation is considered investigational/experimental for the treatment of hypertension due to limited literature and research; it is not covered under the SelectHealth Commercial plan.

Policy states procedure is not covered

Coverage determined by CMS when applicable

Medicare and Community Care (Medicaid)

CMS-directed coverage: Coverage is determined by CMS; if CMS has not adopted a determination and InterQual criteria are not available, the SelectHealth Commercial policy applies.

Providers should consult CMS or state Medicaid resources for current determinations

Initial and maintenance PTNS coverage criteria

Covered when ALL of the following are met

Eligibility and prior therapy: Patient has had OAB symptoms (urgency, frequency, urge incontinence) for at least 12 months with significant disability impacting ADLs; patient has tried behavioral treatments (pelvic floor exercise, biofeedback, timed voids, fluid management) without improvement; and patient has tried at least two different anticholinergic drugs or an anticholinergic plus a tricyclic for 4–6 weeks without improvement or has documented intolerance to these drugs.

Documentation of prior therapies required

Initial treatment course: Initial PTNS is covered as weekly treatments for 12 weeks.12 weekly treatments

Response requirement for maintenance: Patient must demonstrate symptom improvement (documented 50% improvement) to justify maintenance treatments every 1–2 months for the remainder of one year; if no improvement after 6 PTNS treatments, continued treatment is not medically necessary.50% improvement; failure if no improvement after 6 treatments

Retreatment after initial course: Continued treatment after the initial 12 months is not covered unless 24 months have passed since completion of the initial PTNS treatment and the patient has returning symptoms; in such cases, a new PTNS trial (weekly for 12 weeks) is required.24 months

PTNS Initial and Maintenance Criteria

PTNS Coverage and Treatment Limitations (Commercial Plan): Covered when ALL of the following are met

Initial course: Initial PTNS treatments are covered weekly for 12 weeks.12 weeks

Response requirement: Patient must show 50% improvement of OAB symptoms for treatment to be covered every one to two months for the remainder of one year.50% improvement

Early failure: If the patient fails to improve after 6 PTNS treatments, continued treatment is not considered medically necessary.6 treatments

Maintenance duration: Maintenance coverage after the initial 12 weeks is available every one to two months for the remainder of one year.12 months

Retreatment after relapse: Continued treatment after the initial 12 months is not covered unless it has been 24 months since completion of the initial PTNS treatment and the patient has returning symptoms; in these instances a new PTNS trial (weekly for 12 weeks) is required.24 months

Synthetic Bulking Agents Coverage

Synthetic Bulking Agents Coverage (Commercial Plan):

Covered agents: Select Health covers Durasphere, Coaptite, Macroplastique, and Bulkamid for treatment of stress urinary incontinence.

Not covered agents: Other synthetic bulking agents (for example polytetrafluoroethylene [Teflon], silicone microimplants, autologous ear chondrocytes, autologous fat) are considered investigational and not covered.

Covered with criteria

Select Health covers TLV for BPH when clinically appropriate and consistent with product-specific rules

General coverage conditions: Patient has benign prostatic hypertrophy causing obstruction and has failed medical therapy or other minimally invasive therapies (e.g., transurethral needle ablation or microwave therapy); prostate volume is within treatable size (up to 120 cc); procedure is performed by an experienced urologic surgeon.prostate size <= 120 cc

Medicare or State Medicaid coverage determinations supersede commercial criteria when published.

Coverage stance by product

SelectHealth coverage positions:

Commercial/CHIP coverage: Transurethral radiofrequency (RF) for stress urinary incontinence (e.g., Renessa) is not covered as current evidence demonstrates inferior efficacy and durability to standard approaches and is considered not medically necessary.

Apply to SelectHealth Commercial plan and CHIP.

Medicare coverage: Coverage determined by CMS; if CMS has not adopted a determination and InterQual criteria are not available, the SelectHealth Commercial policy applies.

Providers should check CMS coverage database.

Community Care (Medicaid) coverage: SelectHealth Community Care policies typically align with State Medicaid policy; state Medicaid or SelectHealth Community Care rules may apply.

Providers should check state Medicaid resources.

Commercial / CHIP coverage

Covered when ALL of the following are met

Coverage conditions: 1) Male patient aged >= 45 years; 2) Prostate volume less than 100 cc; 3) Failure of >= 3 months of conservative therapy (including trial of both an alpha-1-adrenergic antagonist and a 5-alpha-reductase inhibitor), or intolerance/contraindication to medical therapy.

SelectHealth will cover up to 7 implants; more than 7 requires clinical justification.

Medical necessity criteria for embolization

Percutaneous embolization is covered when ANY one of the following surgical coverage criteria is met or for post-surgical recurrence:

Covered indications: Adolescents with grade 2 or 3 varicoceles associated with ipsilateral testicular growth retardation

Covered under the medical benefit

Covered indications: Scrotal pain associated with varicoceles

Covered under the medical benefit

Covered indications: Males with infertility who have decreased sperm motility and lower sperm concentrations

Covered under the fertility benefit

Covered indication: Post-surgical (ligation) recurrence of varicocele

Allows embolization after recurrence

Modified criteria B (Commercial Plan)

Coverage criteria referenced and revised for Commercial Plan Policy

Criteria B (modified): Either 1) Meets one of the above criteria for surgery OR 2) Post-surgical (ligation) recurrence of varicoceles.

Summary of revision; full criteria text not present in this fragment.

Select Health considers any repeat application of Optilume to be experimental/investigational and not covered due to insufficient data to support safety and efficacy. The policy further states that Optilume is not covered for other indications (including, but not limited to, benign prostatic hyperplasia), as effectiveness for those uses has not been established.

Percutaneous ovarian and pelvic vein embolization should not be performed in patients with significant contraindications to venography or endovascular procedures, including known sensitivities or allergies to contrast material. The policy also cautions about embolization of certain pelvic veins (e.g., internal iliac veins) because of a potential risk of embolic migration and pulmonary embolus.

Penile implants are not covered as a standard benefit under Select Health Commercial and CHIP plans. Coverage is available only for members whose plans include a sexual dysfunction rider and when documentation shows the history/physical is consistent with sexual dysfunction, an organic condition contributing to erectile dysfunction is present, and appropriate medical therapies have been tried and failed. Replacement is covered only when the device malfunctions, breaks, or becomes infected and medical necessity criteria continue to be met; replacements under the manufacturer's warranty are not covered.

For the Select Health Commercial plan the policy designates certain procedures as not covered / investigational. For example, percutaneous renal nerve ablation is considered investigational and not covered because the literature is limited. The policy emphasizes that when a procedure is designated investigational/unproven for the Commercial plan, requests for coverage may be denied.

Select Health considers leadless neuromodulation systems (for example, BlueWind Revi, eCoin, Freedom) and wearable neuromodulation systems (for example, Vivally, ZIDA) to be experimental/investigational and not covered because of safety concerns and lack of established long-term outcomes or demonstrated effectiveness.

Use of leadless tibial or other leadless neuromodulation systems (e.g., BlueWind Revi, eCoin, Freedom) and wearable neuromodulation devices (e.g., Vivally, ZIDA) is explicitly listed as not covered by Select Health for Commercial plans and will be considered experimental/investigational.

Transurethral laser approaches and other prostate procedures have been associated with higher rates of unplanned or prolonged postoperative urinary catheterization and more frequent irritative voiding symptoms compared with some standard techniques. The policy notes these postoperative urinary management issues when describing TLV and related treatments.

Select Health considers transurethral radiofrequency micro-remodeling for stress urinary incontinence (e.g., Renessa, CPT 53860) to be not covered / investigational for the indication listed, citing inferior efficacy and durability compared with standard approaches.

The policy references NICE guidance for the UroLift system and notes that recommended use excludes men with an obstructing middle lobe. UroLift is positioned as an option for prostates without an obstructing middle lobe and generally for men with prostate volume <100 mL, per the referenced clinical guidance.

Select Health does not cover surgical treatment of subclinical varicocele (ligation or embolization) because evidence is insufficient to support effectiveness; such treatments are considered experimental/investigational. In addition, use of certain endoluminal occlusion devices (for example, the ArtVentive EOS) for varicocele is explicitly considered experimental/investigational and is not covered.

The policy includes procedure and diagnosis codes for informational purposes only. Inclusion or exclusion of a code in this document does not by itself determine coverage or guarantee reimbursement; member benefits and eligibility under the individual's contract must be confirmed to determine whether a specific service is covered.

Billing Codes and Key Clinical Thresholds

Covered CPT CodesCPTCovered

52284

Cystourethroscopy, with mechanical urethral dilation and urethral therapeutic drug delivery by drug-coated balloon catheter for urethral stricture or stenosis, male; including fluoroscopy, when performed

Not covered / investigationalCPTNot Covered

0619T

Cystourethroscopy with transurethral anterior prostate commissurotomy and drug delivery, including transrectal ultrasound and fluoroscopy, when performed

Covered CPT CodesCPTCovered

37241	Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (eg, congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles)
75894	Transcatheter therapy, embolization, any method, radiological supervision and interpretation

HCPCS CodesHCPCS

No codes listed

CPT codes for penile implant proceduresCPT

54115	Removal foreign body from deep penile tissue (eg, plastic implant)
54400	Insertion of penile prosthesis; non-inflatable (semi-rigid)
54401	Insertion of penile prosthesis; inflatable (self-contained)
54405	Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders , and reservoir
54408	Repair of component(s) of a multi-component, inflatable penile prosthesis
54410	Removal and replacement of all component(s) of a multi-component, inflatable penile prosthesis at the same operative session
54411	Removal and replacement of all components of a multi-component inflatable penile and debridement of infected tissue
54415	Removal of non-inflatable (semi-rigid) or inflatable (self-contained) prosthesis, without replacement of prosthesis penile
54416	Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) prosthesis at the same operative session penile
54417	Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis through an infected field at the same operative session; including irrigation and debridement of infected tissue

HCPCS / Other device codesHCPCS

C1813	Prosthesis, penile, inflatable
C2622	Prosthesis, penile, noninflatable
L8699	Prosthetic implant, not otherwise specified

Not covered / Investigational CPT/Category IIICPTNot Covered

0338T	Transcatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy; contrast njection(s), intraprocedural roadmapping and radiological supervision and interpretation, including pressure gradient measurements, flush aortogram and diagnostic renal angiography when performed; unilateral
0339T	Transcatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast injection(s): intraprocedural roadmapping and radiological supervision and interpretation; including pressure gradient measurements , flush aortogram and diagnostic renal angiography when performed; bilateral

Not covered / Investigational CPT/Category IIICPTNot Covered

0339T

Transcatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies) , fluoroscopy, contrast injection(s) : intraprocedural roadmapping and radiological supervision and interpretation; including pressure gradient measurements , flush aortogram and diagnostic renal angiography when performed; bilateral

HCPCSHCPCS

No codes listed

Covered CPT CodesCPTCovered

64566

Posterior tibial neurostimulation, percutaneous needle electrode, single treatment;, includes programming

Surgical CPT Codes (Implantable Systems)CPT

0816T	Open insertion or replacement of integrated neurostimulation system for bladder dysfunction including electrode(s) (eg, array or leadless), and pulse generator or receiver; including analysis, programming, and imaging guidance; when performed, posterior tibial nerve; subcutaneous
0817T	Open insertion or replacement of integrated neurostimulation system for bladder dysfunction including electrode(s) (eg, array or leadless), and pulse generator or receiver; including analysis, programming, and imaging guidance; when performed, posterior tibial nerve; subfascial
0818T	Revision or removal of integrated neurostimulation system for bladder dysfunction; including analysis programming, and imaging, when performed , posterior tibial nerve, subcutaneous
0819T	Revision or removal of integrated neurostimulation system for bladder dysfunction; including analysis programming, and imaging, when performed, posterior tibial nerve, subfascial
64590	Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling

HCPCS CodesHCPCS

E0737

Transcutaneous tibial nerve stimulator; controlled by phone application

Covered CPT CodesCPTCovered

51715	Endoscopic injection of implant material into the submucosal tissues of the urethra andlor bladder neck
52327	Cystourethroscopy (including ureteral catheterization); with subureteric injection of implant material

Covered HCPCS CodesHCPCSCovered

L8603	Injectable bulking agent; collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies
L8604	Injectable bulking agent; dextranomer/hyaluronic acid copolymer implant, urinary tract, ml, includes shipping and necessary supplies
L8606	Injectable bulking agent synthetic implant, urinary tract; ml syringe, includes shipping and necessary supplies

CPT CodesCPTCovered

52648

Laser vaporization of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy , cystourethroscopy, urethral calibration and/or dilation, internal urethrotomy and transurethral resection of prostate are included if performed)

HCPCS CodesHCPCS

C1726	Catheter; balloon dilatation, non-vascular
C1758	Catheter, ureteral
C1769	Guide wire
C1782	Morcellator
C2627	Catheter; suprapubic/cystoscopic

Not covered / Investigational CPT CodesCPTNot Covered

53860

Transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence

HCPCS CodesHCPCS

No codes listed

CPT CodesCPTCovered

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)

HCPCS CodesHCPCSCovered

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

Billing/CPT CodesCPT

37241	Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation; intraprocedural roadmapping , and imaging ance necessary to complete the intervention; venous, other than hemorrhage (eg, congenital or acquired venous malformations, venous and capillary hemangiomas, varices , varicoceles) guida
55530	Excision of varicocele or ligation of spermatic veins for varicocele; (separate procedure)
55535	Excision of varicocele or ligation of spermatic veins for varicocele; abdominal approach
55540	Excision of varicocele or ligation of spermatic veins for varicocele; with hernia repair
55550	Laparoscopy, surgical, with ligation of spermatic veins for varicocele

HCPCS CodesHCPCS

No codes listed

Informational note about codesmixed

No codes listed

inv-60: Maximum stricture length — key clinical threshold

Maximum stricture length< 3 cm (Optilume is designed to treat strictures under 3 cm in adult males)

Patient age requirementAdult males ≥ 18 years

Stricture location requirementRecurrent bulbar urethral strictures (per coverage criteria)

inv-61: Pelvic pain duration — key clinical threshold

Minimum duration of pelvic pain>= 6 months (chronic, noncyclic pelvic pain required for PCS diagnosis)

Associated imaging requirementImaging consistent with pelvic venous changes (documentation required)

Conservative therapy prerequisiteTried and failed conservative therapy of at least 3 months (include prescription anti-inflammatories unless contraindicated)

inv-62: Conservative therapy duration — key clinical threshold

Minimum conservative therapy duration>= 3 months (required before endovascular treatment for PCS/pelvic varicosities)

Includes prescription anti-inflammatoriesConservative therapy must include prescription anti-inflammatories unless contraindicated

Documentation requirementRecords must show failure of conservative measures prior to intervention

inv-63: Varicose vein diameter — key clinical threshold

Minimum vein diameter for treatment>= 4 mm (varicose veins to be treated must be 4 mm or greater in diameter)

Functional impact requirementPatient unable to perform ADLs for pelvic/labial varicosities eligibility

Conservative therapy prerequisiteFailed at least 3 months of conservative therapy including prescription anti-inflammatories

inv-64: Initial PTNS course — key clinical threshold (weekly x12 weeks)

Initial PTNS regimenWeekly treatments for 12 weeks (initial course)

Maintenance cadence after initial courseIf effective, maintenance every 1–2 months for remainder of one year

Documentation for PAPrior authorization requires documentation of indication, prior therapies, and response to initial 12-week course

inv-65: Improvement threshold — 50% improvement required and failure after 6 treatments (operational)

Improvement required to continue therapyDocumented >= 50% improvement in OAB symptoms is required to justify ongoing maintenance PTNS

Failure definitionFailure defined as lack of improvement after 6 PTNS treatments — continued treatment then not medically necessary

Objective documentationProviders should document number of PTNS treatments and objective evidence of ≥50% improvement when claiming maintenance coverage

inv-66: Retreatment interval — 24 months before retreatment unless symptoms recur and new 12-week trial completed

Minimum interval before retreatment24 months since completion of the initial PTNS course before re-initiating maintenance coverage (unless symptoms recur and a new 12-week trial is completed)

Exception for symptom recurrenceIf symptoms recur after 24 months, a new 12-week PTNS trial (weekly) is required before maintenance coverage

Continuation rulesContinued treatment after initial 12 months is not covered unless retreatment timing and trial conditions are met

inv-67: Symptom improvement threshold — 50% improvement required for maintenance PTNS coverage

Symptom improvement threshold for maintenance>= 50% documented improvement in OAB symptoms required for maintenance PTNS coverage

Maintenance frequency if improvedMaintenance treatments every 1–2 months for the remainder of one year

Failure stop-gapIf no improvement after 6 treatments, continued PTNS is not medically necessary

inv-68: Prostate volume threshold for UroLift/related coverage

Prostate volume limit< 100 cc (prostate volume must be less than 100 cc for UroLift coverage)

Patient age for UroLiftTypically performed in men; coverage criteria reference men ≥ 45 years (see age threshold block)

Maximum implants without justificationSelectHealth will cover up to 7 UroLift implants; >7 requires clinical justification

inv-69: Age threshold for coverage (UroLift)

Minimum age for UroLift coverage≥ 45 years (men must be at least 45 years old)

Gender specificationApplies to male patients (prostatic urethral lift)

Coverage pairingAge requirement is part of Commercial/CHIP coverage conditions for UroLift

inv-70: Prior medical therapy duration required

Required prior medical therapy duration>= 3 months (failure of ≥3 months conservative therapy required before UroLift; must include trial of both an alpha-1 blocker and a 5-alpha-reductase inhibitor unless intolerant)

Therapy componentsConservative therapy includes alpha-1-adrenergic antagonist + 5-alpha-reductase inhibitor, or documented intolerance/contraindication

Documentation needPrior therapy attempts and failures must be documented for prior authorization and coverage

Prior Authorization, Documentation, and Denial Triggers

Prior Authorization

Prior Authorization Required — Optilume (CPT 52284)

Prior authorization required for Optilume (CPT 52284) when applicable. Providers must submit documentation demonstrating member is ≥18 years old, has urinary symptoms associated with a urethral stricture, stricture length <3 cm, and recurrent bulbar urethral strictures. Repeat Optilume applications are not covered (considered experimental/investigational). Optilume use for other indications (e.g., BPH) is not covered.

Prior auth applies to CPT 52284
Required documentation: age, symptoms, stricture length (<3 cm), location (bulbar), prior treatments/recurrence
Repeat applications denied as investigational
Other indications (e.g., BPH) denied as investigational

Prior Authorization

Prior Authorization and Documentation — Embolization Procedures

Prior authorization required for embolization procedures (e.g., pelvic congestion syndrome embolization and varicocele embolization). Providers must document clinical indication, duration of symptoms, imaging consistent with venous changes, failure of ≥3 months conservative therapy (including prescription anti-inflammatories unless contraindicated), and ADL impact when relevant. For varicocele embolization, documentation must support surgical criteria or post-surgical recurrence.

Affected CPT codes: 37241, 75894 (embolization/ transcatheter therapy)
Pelvic congestion: pelvic pain ≥6 months, imaging, failed conservative therapy ≥3 months
Varicocele embolization: must meet surgical criteria (e.g., adolescent testicular growth retardation, symptomatic scrotal pain, infertility with abnormal semen parameters) OR post-surgical recurrence
Varicose veins to be treated must be ≥4 mm diameter (pelvic/labial varicosities)

Documentation Required

Verify Benefits and Obtain Prior Authorization

Coverage and prior authorization expectations across interventions: verify member benefits and eligibility prior to the service. Codes listed in policies are informational only and inclusion does not guarantee coverage. Providers should obtain required prior authorization and supply the clinical documentation specified in the policy to support medical necessity.

Verify member benefits and eligibility before scheduling/performing services
Coding lists are informational — check the member's contract for coverage
Contact Provider Relations or Member Customer Service for benefit questions

Prior Authorization

Prior Authorization Required — PTNS (Posterior Tibial Nerve Stimulation)

Posterior tibial nerve stimulation (PTNS) requires prior authorization documenting indication and prior therapies. Initial PTNS is covered only when documentation shows OAB symptoms for ≥12 months with significant ADL impact, failure or intolerance of at least two anticholinergic agents (or anticholinergic + tricyclic) for 4–6 weeks, and prior behavioral therapies. Treatment and coding (CPT/HCPCS) are subject to the policy's coverage and treatment-limit criteria.

Documented OAB duration ≥12 months and ADL impact
Trials of ≥2 pharmacologic agents (or intolerance) required
Behavioral therapy trial documented (pelvic floor, biofeedback, timed voids, fluid management)
Billing/coding informational — follow policy for covered PTNS codes

Note

Coverage Statements and Affected CPTs

Coverage statement and affected CPT: TLV is covered when criteria are met (see TLV policy); CPTs in that policy should be used per clinical criteria. Conversely, certain procedures (e.g., transurethral RF for SUI — Renessa) are not covered (considered not medically necessary) and CPTs for those procedures are noted as not covered/experimental.

Transurethral laser vaporization (TLV) covered when criteria met (see TLV policy)
Renessa/transurethral RF for SUI considered not medically necessary — associated CPTs listed as not covered/experimental

Prior Authorization

Coverage and Prior Authorization — Summary

Summary of coverage and prior authorization expectations for a range of interventions: some minimally invasive therapies (e.g., UroLift) are covered with explicit prior therapy and patient criteria; other interventions are considered investigational and will be denied. Providers must follow plan-specific prerequisites and provide documentation to justify clinical necessity.

UroLift: prior conservative therapy required, age and prostate volume limits, maximum implant count (≤7) — >7 requires clinical justification
Medicare/Medicaid may have different determinations — Commercial criteria apply when CMS criteria absent
Investigational procedures (e.g., Renessa, leadless neuromodulation) will be denied

Prior Authorization

Prior Authorization and Coverage Conditions — UroLift

Prior authorization and coverage conditions for specific devices/procedures: UroLift coverage requires men ≥45 years old, prostate volume <100 cc, and failure of ≥3 months conservative therapy including trials of both an alpha-1 antagonist and a 5-alpha-reductase inhibitor unless contraindicated or not tolerated. Requests for second UroLift procedures or >7 implants require clinical justification.

UroLift criteria: age ≥45, prostate volume <100 cc, failed ≥3 months conservative therapy including both medication classes
Maximum of 7 implants covered; >7 needs justification
Second procedures require explanation why other prostate removal procedures are not clinically indicated

Prior Authorization

Authorization and Documentation — Embolization and Varicocelectomy

Prior authorization required for embolization and varicocelectomy codes. Documentation must support one of the covered surgical indications (adolescent testicular growth retardation, symptomatic scrotal pain, infertility with abnormal semen parameters) or post-surgical recurrence. Subclinical varicocele treatments and endoluminal occlusion devices are considered experimental/investigational and will be denied.

Affected codes include CPT 37241 and related surgical CPTs (e.g., 55530, 55535, 55540, 55550)
Documentation must support covered surgical indications or post-surgical recurrence
Subclinical varicocele treatment is not covered
Endoluminal occlusion devices (e.g., ArtVentive EOS) considered investigational and not covered

Documentation Required

Authorization Depends on Member Benefits — Verify Before Service

Authorization and coverage decisions depend on the member's individual benefit plan and eligibility. Providers must verify benefits and obtain any required authorizations before providing services. Failure to verify benefits may lead to claim denials.

Verify benefits and eligibility at time of service
Obtain required prior authorizations per member plan
Contact Provider Relations or Member Customer Service for benefit questions

Denial Risk

Denial Triggers and Warranty Exclusions

Denial triggers and warranty exclusions: replacements of devices (e.g., penile implants) are covered only when medically necessary and not covered if the replacement is part of the manufacturer's warranty. Lack of required documentation (pain duration, imaging, failure of conservative therapy, prior treatment trials, improvement thresholds) may trigger denial.

Penile implant replacements covered only if device fails, is infected, or broken AND replacements are not under manufacturer's warranty
Denial triggers include missing documentation of required symptom duration, imaging, conservative therapy failure, or required prior trials
Providers must document clinical rationale for device replacement when applicable

Denial Risk

PTNS Continuation Denial Triggers and Experimental Device Exclusions

Denial triggers for PTNS continuation and experimental device exclusions: continued PTNS beyond the initial trial without improvement or outside permitted retreatment timing may be denied. If patient fails to improve after 6 PTNS treatments, continued PTNS is not medically necessary. Leadless or wearable neuromodulation systems (e.g., BlueWind Revi, eCoin, Freedom, Vivally, ZIDA) are considered experimental/investigational and will be denied.

Initial PTNS: weekly for 12 weeks; must show ≥50% symptom improvement to continue coverage
If no improvement after 6 treatments, continued PTNS is not medically necessary
Maintenance/retreatment allowed only per policy timing (e.g., new 12-week trial if ≥24 months since prior course)
Leadless and wearable neuromodulation devices are investigational — denials expected

Documentation Required

Required Clinical Documentation — What to Submit

Required clinical documentation — general guidance: providers must supply supporting history and physical exam, symptom duration, prior treatment trials and responses, imaging results when applicable, objective measures of improvement (e.g., ≥50% symptom improvement for PTNS), and any device-specific details (e.g., implant counts for UroLift). Documentation should support one of the covered indications listed in each policy.

Include history/physical consistent with the diagnosis (e.g., sexual dysfunction for penile implants)
Document duration of symptoms and prior conservative therapies with dates and responses
Provide imaging reports when required (e.g., pelvic venous changes, varicocele sizing)
For PTNS, document number of treatments, objective evidence of ≥50% improvement, and timing of maintenance/retreatment

Clinical Background and Definitions

Urethral stricture is an abnormal narrowing of the urethra that can result from acute injury, inflammation, postsurgical complications, infection, or malignancy. Patients typically present with obstructive and irritative urinary symptoms such as decreased urinary stream, incomplete bladder emptying, dysuria, hematuria, leakage, and recurrent urinary tract infections. Although endoscopic treatments (dilation, direct vision internal urethrotomy) are commonly used, they have high recurrence rates; urethroplasty remains the reference standard for durable repair in many cases.

inv-120: Optilume urethral drug-coated balloon (DCB) — device definition and use for strictures <3 cm

Device definitionOptilume urethral drug-coated balloon (DCB): a balloon catheter that dilates strictured urethral segments and delivers paclitaxel into tissue to limit cell proliferation

Indicated stricture lengthDesigned for treatment of urethral strictures < 3 cm in adult males

Procedure settingInserted transurethrally during an outpatient cystoscopic procedure to dilate the stricture and deliver drug coating

inv-121: Urethral stricture (US) — definition and clinical presentation

DefinitionUrethral stricture (US): an abnormal narrowing of the urethra caused by injury, inflammation, postsurgical complications, infection, or cancer; presents with decreased urinary stream, incomplete emptying, dysuria, hematuria, leakage, and UTIs

Anatomic typesCan be anterior or posterior; anterior strictures comprise the majority of cases

Treatment contextUrethroplasty is the reference standard; endoscopic treatments have high recurrence, especially with repeat interventions

inv-122: Pelvic congestion syndrome (PCS) — definition and diagnostic thresholds

DefinitionPelvic congestion syndrome (PCS): condition caused by utero-ovarian varices presenting as chronic, noncyclic pelvic pain (often worsened when standing) with engorged pelvic veins (>10 mm on venography)

Typical patient populationMost commonly multiparous, premenopausal women, though nulliparous women can be affected

Associated featuresMay include pelvic varices in thigh, buttock, perineum, vulva, or vagina; symptoms may increase after childbirth

inv-123: Percutaneous transcatheter coil embolization — definition and procedural note

Procedure definitionPercutaneous transcatheter coil embolization: endovascular access (commonly via femoral vein) to the ovarian vein with deployment of coils, plugs, or use of sclerosing agents under fluoroscopic guidance

Treatment intentUsed to occlude pelvic varices as alternative to surgery or adjunct to other embolic techniques

Technical noteIliac vein embolization may be required in some cases due to ovarian–iliac venous communications

inv-124: Erectile Dysfunction (ED) — definition

DefinitionErectile dysfunction (ED): inability to attain and maintain an erection sufficient for sexual intercourse; may be organic or psychogenic

Clinical relevanceSevere ED associated with advanced diabetes, prior pelvic surgery/radiation, or Peyronie’s disease may require prosthetic implantation

inv-125: Penile implant types — semi-rigid, two-piece inflatable, three-piece inflatable

Types of implantsSemi-rigid (malleable), two-piece inflatable, and three-piece inflatable penile implants

Component descriptionThree-piece inflatable implants include inflatable cylinders, abdominal reservoir, and scrotal pump

FDA device classesRigid implants: Class II; inflatable implants: Class III (per policy text)

inv-126: Resistant hypertension — definition

Definition of resistant hypertensionFailure to achieve goal BP despite adherence to an appropriate 3‑drug regimen including a diuretic (goal generally <140/90 mmHg)

Clinical measurementBased on averages from multiple visits; higher value (systolic or diastolic) determines severity

Context for interventionsRenal sympathetic denervation targets renal sympathetic nerves adjacent to renal artery wall

inv-127: Overactive bladder (OAB) — syndrome definition

Definition of OABOveractive bladder (OAB): syndrome of urinary urgency, frequency, and/or urge urinary incontinence that can significantly impact ADLs

Treatment contextIncludes behavioral therapies, pharmacologic agents, and neuromodulation options such as PTNS

Documentation needsDuration (>=12 months) and impact on ADLs required for PTNS consideration

inv-128: Contraindications for PTNS — list of contraindications

Contraindications for PTNSPresence of pacemaker/implantable defibrillator, bleeding disorders/prone to excessive bleeding, nerve damage affecting tibial/pelvic floor function, pregnancy or planning pregnancy

Experimental exclusionsLeadless neuromodulation systems and wearable neuromodulation systems are not covered per exclusions

Cautionary noteProviders should document absence of contraindications when requesting PTNS coverage

inv-129: Periurethral bulking agents — definition

DefinitionPeriurethral bulking agents: injectable substances placed in submucosal tissues of the urethra/bladder neck to increase tissue bulk and resistance to urinary outflow for SUI treatment

ExamplesDurasphere, Coaptite, Macroplastique, Bulkamid (covered agents); other agents like Teflon, silicone microimplants are investigational

Use considerationsOften used in women; may require multiple injections and may need retreatment as some agents are absorbed over time

inv-130: Leadless neuromodulation systems — definition and examples

DefinitionLeadless neuromodulation systems: implantable tibial or other neuromodulation devices without percutaneous leads (e.g., BlueWind Revi, eCoin, Freedom) considered experimental/investigational

Coverage stanceSelectHealth does not cover these systems due to safety concerns and lack of long-term outcomes

ExamplesBlueWind Revi, eCoin, Freedom (leadless); Vivally and ZIDA (wearable) listed as not covered

inv-131: Transurethral Laser Vaporization (TLV) — definition

DefinitionTransurethral Laser Vaporization (TLV): contact laser technique vaporizing prostate tissue by maintaining laser fiber in contact and creating furrows until a wide channel is obtained

IndicationUsed for BPH in patients who fail medical or other minimally invasive therapies; prostate size limit ~120 cc

Outcomes noteMay have higher rates of postoperative catheterization and irritative voiding symptoms compared with TURP

inv-132: Transurethral radiofrequency (RF) / Renessa — definition

DefinitionTransurethral radiofrequency (RF) / Renessa: transurethral RF procedure denaturing collagen at multiple small sites in bladder neck/proximal urethra to increase tissue firmness and reduce SUI

Coverage stancePolicy lists transurethral RF (e.g., Renessa) as investigational/not covered for SUI

MechanismLow-temperature RF causes tissue remodeling to increase urethral resistance

inv-133: UroLift — definition

DefinitionUroLift: prostatic urethral lift system that places transprostatic implants to hold prostatic lobes apart and reduce urethral obstruction

Typical implants per procedureAverage ~4 implants used per procedure (range 2–7); SelectHealth covers up to 7 without extra justification

Intended effectRelieves BPH-LUTS by mechanically widening the prostatic urethra without tissue removal

inv-134: BPH-LUTS — definition abbreviation

AbbreviationBPH-LUTS: benign prostatic hyperplasia causing lower urinary tract symptoms

Clinical contextRefers to symptomatic BPH with obstructive urinary symptoms

inv-135: Varicocele grading — grade definitions

Varicocele gradingGrade 1: small, palpable only; Grade 2: moderate, palpable without Valsalva; Grade 3: large, visible

Diagnostic methodPhysical exam and ultrasonography used for diagnosis; ultrasound most practical noninvasive test

inv-136: Subclinical varicocele — definition and coverage stance

DefinitionSubclinical varicocele: varicocele detectable only by imaging and not palpable

Coverage stanceTreatment of subclinical varicocele (surgical ligation or embolization) is considered experimental/investigational and not covered

Clinical implicationDocumentation must support clinical indications (pain, infertility, testicular growth retardation) for coverage

inv-137: Varicocele embolization — definition and procedural overview

DefinitionVaricocele embolization: percutaneous transcatheter occlusion of spermatic/testicular veins using coils, plugs, or sclerosing agents as treatment for varicocele

IndicationsUsed for symptomatic varicocele (pain), adolescent testicular growth retardation, or infertility with abnormal semen parameters; covered when criteria met

Technical noteProcedure often performed via transvenous access with fluoroscopic guidance; various embolic materials reported in literature