ModifiedSelectHealthPolicy 672

Optilume urethral drug-coated balloon (DCB) — Coverage Criteria

SelectHealth coverage policy for the Optilume urethral drug-coated balloon for treatment of urethral strictures, including coverage criteria, exclusions, contraindications, and applicable CPT codes; applies to SelectHealth Commercial, Medicare (when CMS has no determination), and SelectHealth Community Care (Medicaid) where noted.

Policy Summary

PayerSelectHealth

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

Policy CodePolicy 672

Change TypeMultiple material revisions (added exclusionsclarified criteria)

Effective DateSep 26, 2023

Next Review DateN/A

Key ActionVerify member benefits and obtain prior authorization documenting clinical criteria before requesting coverage for Optilume.

SourceLink

POLICY UPDATE CHANGES

For Commercial Plan Policy, revised exclusionary statement regarding repeat applications: Select Health does not cover any repeat applications of Optilume as there is insufficient data to support safety and efficacy.

Added exclusion: Select Health does not cover Optilume for the treatment of any other indication, including but not limited to benign prostatic hyperplasia (BPH).

For Commercial Plan Policy, aligned requirements for failure of conservative therapy in criterion #1-C with those listed in criterion #2-B.

For Commercial Plan Policy, modified criteria for Treatment Limitations in section B including initial PTNS frequency, stopping rule after 6 treatments, retreatment timing, contraindications moved or clarified.

Added exclusion: Select Health does not cover BlueWind Revi and eCoin leadless tibial neurostimulators (later expanded to leadless systems and wearable neuromodulation systems).

Modified requirements in section B to require a 50% improvement of OAB symptoms for coverage of maintenance PTNS treatments every one to two months after the initial 12 weeks.

For Commercial Plan Policy, added Bulkamid to list of products eligible for coverage.

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

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

0.9%annual US incidence

52284covered CPT

0619T,52443not covered CPTs

12 wksPTNS initial course

6PTNS stop rule

severalreview entries

Coverage Criteria and Medical Necessity

Prior Authorization

Provider Action: Prior Authorization, Benefits, and Documentation Requirements

Prior authorization and benefit verification required. Coverage decisions depend on the member's specific benefit plan and any applicable riders (e.g., sexual dysfunction rider for penile implants). Inclusion of codes in this policy does not guarantee coverage—verify member benefits and obtain prior authorization when noted below. Failure to meet documented criteria or lack of prior authorization may result in denial of payment.

Providers must verify member benefits and obtain prior authorization for procedures described in this section before scheduling services.
Prior authorization must include documentation that demonstrates the member meets all applicable coverage criteria listed in the policy (medical history, prior therapies, imaging, symptom duration, objective measures, and trial of conservative therapy as required).
For pelvic vein embolization (pelvic congestion syndrome or pelvic/labial varicosities): prior authorization required. Documentation must show duration of symptoms, imaging consistent with pelvic venous changes, failure of ≥3 months conservative therapy (including prescription anti-inflammatories unless contraindicated), and for labial/pelvic varicosities demonstrate ADL impairment and vein diameter ≥4 mm when applicable.
For Posterior Tibial Nerve Stimulation (PTNS): prior authorization required. Documentation must show patient is ≥18 years, OAB symptoms ≥12 months with significant disability, failure of at least two different anticholinergic drugs (or anticholinergic+tricyclic) for 4–6 weeks or intolerance/contraindication, and failure of behavioral therapies. Initial PTNS coverage is weekly ×12; continued coverage requires ≥50% symptom improvement and documented maintenance schedule per policy.
PTNS contraindications (e.g., pacemaker/ICD, bleeding risk, nerve damage, pregnancy) must be documented; leadless or wearable neuromodulation systems are considered experimental/investigational and are not covered.
Penile implants: prior authorization required only when member has a sexual dysfunction rider and all device-specific criteria are met (organic etiology, prior appropriate covered medical therapies tried and failed). Replacements covered only for malfunction, infection, or breakage with continued medical necessity and not covered under manufacturer warranty.
UroLift: prior authorization required. For men >45 years with prostate <100 cc, documentation must show ≥3 months failed conservative therapy including both an alpha-1 blocker and a 5-alpha-reductase inhibitor unless intolerant or contraindicated. Requests for >7 implants require supporting clinical justification. Second procedures require explanation why other options are not clinically indicated.
Varicocele embolization: prior authorization required. Documentation must show member meets surgical criteria (e.g., adolescents with testicular growth retardation, scrotal pain, or infertility with impaired semen parameters) OR post-surgical recurrence. Surgical treatment for subclinical varicocele and endoluminal occlusion devices are not covered.
Optilume: prior authorization required where applicable; repeat applications are not covered and will be denied as experimental/investigational. Use of Optilume for other indications (e.g., BPH) is not covered and will be denied as experimental/investigational.
Transurethral radiofrequency (RF) for SUI (e.g., Renessa) is not covered — prior authorization will not be approved.
Synthetic bulking agents not listed as covered (e.g., Teflon, silicone microimplants, autologous fat) are investigational and not covered; prior authorization for these agents will be denied.
When quantity or device limits are exceeded (e.g., >7 UroLift implants), prior authorization must include clinical justification; excess implant requests without justification are subject to denial.
If documentation reveals failure to meet required criteria (including required medication trials, conservative therapy, or objective findings), coverage will be denied. Providers should include prior therapy dates, doses, reasons for intolerance, and objective measures of symptom severity in authorization requests.
Benefit verification is recommended as the first step — contact the member's customer service or Provider Relations for plan-specific requirements and to confirm whether a rider or additional benefits apply.
Policy code listings are informational only. Inclusion/exclusion of codes does not imply coverage. Providers should obtain a coverage determination prior to performing services.

Documentation Required

Prior Authorization Documentation — Required Elements

Prior authorization requests should include: member identifiers, relevant ICD-10 diagnosis codes, proposed CPT/HCPCS/procedure codes, clinical history, relevant imaging reports, prior treatment documentation (medication names, doses, dates, responses or intolerances), physical exam findings, and any specialty-specific assessments (e.g., semen analysis for varicocele infertility). For PTNS, include baseline symptom measures and documentation of ≥50% improvement during the initial trial when requesting maintenance treatments.

Include objective documentation of symptom duration and severity (e.g., imaging for pelvic venous disease; semen analyses for infertility; prostate volume for UroLift).
For medication trials, document drug names, duration (e.g., 4–6 weeks for anticholinergics), dose, and reason for discontinuation if intolerant.
For repeat procedures, provide detailed justification explaining why alternate, less invasive or standard surgical options are not clinically appropriate.
For devices and implants, include prior device history, manufacturer warranty status (for replacements), and evidence of device malfunction/infection if applicable.

Note

Benefit Rider and Prior Therapy Verification

Coverage contingent on benefit rider and prior therapies: Certain procedures (e.g., penile implants) are covered only if the member's plan includes a specific rider and required conservative/medical therapies have been tried and failed. Always verify benefit rider applicability before requesting authorization.

Penile implants require a sexual dysfunction rider and documented failure of appropriate medical therapies.
UroLift and other BPH procedures require documented prior conservative therapy per policy before authorization.
If the member's contract does not include the necessary rider or benefit, the service may be denied even if clinical criteria are met.

Billing and Code References

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 / Investigational CPT CodesCPTNot Covered

0619T	Cystourethroscopy with transurethral anterior prostate commissurotomy and drug delivery, including transrectal ultrasound and fluoroscopy, when performed
52443	Cystourethroscopy with initial transurethral anterior prostate commissurotomy with a nondrugcoated balloon catheter followed by therapeutic drug delivery into the prostate by a drug-coated balloon catheter, including transrectal ultrasound and fluoroscopy, when performed

CPT Codes for Embolization ProceduresCPTCovered

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 Codes (embolization section)HCPCS

No codes listed

Other CPT Codes (document-wide)CPT

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 prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue.
54415	Removal of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis, without replacement of prosthesis.
54416	Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis at the same operative session.
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.

1–10 of 18

1/2

HCPCS Codes (document-wide)HCPCS

C1813	Prosthesis, penile, inflatable
C2622	Prosthesis, penile, noninflatable
L8699	Prosthetic implant, not otherwise specified
C1726	Catheter, balloon dilatation, non-vascular
C1758	Catheter, ureteral
C1769	Guide wire
C1782	Morcellator
C2627	Catheter, suprapubic/cystoscopic
C9739	Cystourethroscopy with insertion of transprostatic implant 1 to 3 implants
C9740	Cystourethroscopy with insertion of transprostatic implant; 4 or more implants

Not Covered CPT Codes (Renal Denervation)CPTNot Covered

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

HCPCS Codes (nearby section)HCPCS

No codes listed

Covered CPT Codes - PTNSCPTCovered

64566

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

Not covered / leadless or implantable system CPT CodesCPTNot Covered

0816T	Open insertion or replacement of integrated neurostimulation system for bladder dysfunction ... posterior tibial nerve; subcutaneous
0817T	Open insertion or replacement of integrated neurostimulation system for bladder dysfunction ... posterior tibial nerve; subfascial
0818T	Revision or removal of integrated neurostimulation system for bladder dysfunction ... posterior tibial nerve, subcutaneous
0819T	Revision or removal of integrated neurostimulation system for bladder dysfunction ... posterior tibial nerve, subfascial
64590	Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling

HCPCS Codes - Wearable/Experimental NeuromodulationHCPCSNot Covered

E0737

Transcutaneous tibial nerve stimulator, controlled by phone application

CPT Codes for Bulking Agent ProceduresCPTCovered

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

Covered CPT Codes - Bulking Agent InjectionCPTCovered

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

HCPCS Codes - Bulking AgentsHCPCSCovered

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, 1 ml, includes shipping and necessary supplies
L8606	Injectable bulking agent synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies

Covered CPT Codes - TLV ProstatectomyCPTCovered

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 Codes - Related Devices (TLV section)HCPCS

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

CPT Codes (document block)CPT

52648

HCPCS Codes (document block)HCPCS

C1726	Catheter, balloon dilatation, non-vascular
C1758	Catheter, ureteral
C1769	Guide wire
C1782	Morcellator
C2627	Catheter, suprapubic/cystoscopic
C1813	Prosthesis, penile, inflatable
C2622	Prosthesis, penile, noninflatable
L8699	Prosthetic implant, not otherwise specified

CPT Codes (RF procedures section)CPT

53860

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

Listed CPT Codes for UroLiftCPTCovered

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)

Listed HCPCS Codes for UroLiftHCPCSCovered

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

Additional Listed CPT CodesCPT

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 prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue.
54415	Removal of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis, without replacement of prosthesis.
54416	Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis at the same operative session.
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.

1–10 of 14

1/2

HCPCS Codes (other section)HCPCS

No codes listed

Varicose vein diameter

Varicose vein minimum diameter>= 4 mm

ContextApplies to pelvic/labial varicosities being considered for embolization or other procedural treatment

Documentation requirement

Prior Authorization, Documentation, and Provider Steps

Billing Rule

Prior auth and coding — Optilume CPT guidance

CPT 52284 is listed as covered when the Optilume coverage criteria are met; related codes 0619T and 52443 are listed as not covered (investigational) for the indications described.

Use CPT 52284 for Optilume procedures when documentation meets policy criteria
Do not bill 0619T or 52443 for covered Optilume indications (listed as investigational/not covered)

Prior Authorization

Prior authorization for pelvic vein embolization — document required criteria

Select Health covers pelvic vein embolization (coils, plugs, transcatheter sclerotherapy) only when documentation meets the stated clinical criteria for PCS or pelvic/labial varicosities; verify benefits and obtain prior authorization as required by the member's plan.

Document pelvic pain ≥6 months, imaging consistent with pelvic venous changes, and failed ≥3 months conservative therapy including prescription anti-inflammatories for PCS

Background, Definitions, and Scope

Urethral stricture is an abnormal narrowing of the urethra resulting from injury, inflammation, prior surgery, infection, or malignancy. Anterior (bulbar) strictures account for the majority of cases and present with symptoms such as decreased urinary stream, incomplete emptying, dysuria, hematuria, urinary leakage, and recurrent urinary tract infections. Treatment options range from dilation and direct vision internal urethrotomy to urethroplasty (the reference standard); selection depends on stricture location, length, etiology, and recurrence history. Repeated endoscopic treatments have high recurrence rates and can complicate future urethroplasty, which is why the policy emphasizes appropriate patient selection and documentation for procedures like Optilume.

Optilume urethral drug-coated balloon (DCB)

Device typeBalloon catheter with antiproliferative drug coating (paclitaxel)

MechanismDilation by radial force plus local drug release to inhibit scar formation and reduce stricture recurrence

Use settingInserted into urethra during outpatient procedure; balloon inflated at stricture site to deliver drug and dilate lumen

Policy Changes and Revision History

2025-06-24clarifiedLatest

Modified PTNS treatment limitations to require a ≥50% improvement of OAB symptoms for maintenance coverage and reiterated retreatment timing after 24 months; contraindication wording moved to exclusions.

2025-05-27clarified

Aligned requirements for failure of conservative therapy in criterion #1-C with those listed in criterion #2-B for the Commercial Plan Policy.

2025-05-05added

Policy Summary

PayerSelectHealth

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

Policy CodePolicy 672

Change TypeMultiple material revisions (added exclusionsclarified criteria)

Effective DateSep 26, 2023

Next Review DateN/A

Key ActionVerify member benefits and obtain prior authorization documenting clinical criteria before requesting coverage for Optilume.

SourceLink

On This Page

Imaging or examination must demonstrate veins >=4 mm to meet coverage criteria

Symptom improvement threshold

Symptom improvement threshold>=50% improvement of OAB symptoms

UseRequired to qualify for maintenance PTNS coverage every 1–2 months for remainder of one year after initial 12-week course

Assessment timingMeasured after the initial 12 weekly PTNS treatments

Duration of symptoms

Minimum symptom duration>=12 months

Applies toOveractive bladder (OAB) coverage criteria requiring significant disability limiting ADLs

DocumentationClinical record must show duration >=12 months and failed conservative therapies

Prostate size limit for TLV

Prostate size limit for TLV<= 120 cc

Clinical noteProstates up to ~120 cc can be treated with TLV; larger prostates often managed with open enucleation

ImplicationProstate volume should be documented when requesting TLV coverage

Pre-embolization semen density

Pre-embolization semen density (study subgroup)10 to 30 million/ml

FindingSubgroup with pre-embolization semen density 10–30M/ml showed significant semen quality improvement after embolization

Clinical relevanceImprovement in semen parameters did not consistently correlate with pregnancy rates

Eligibility example in randomized trial

Trial eligibility exampleInfertility >=1 year; palpable Grade 2 varicocele; at least one impaired semen parameter (eg sperm concentration <20M/ml, progressive motility <50%, or normal morphology <30%)

Age range (trial)Married men aged 20–39 in cited RCT

ExclusionsSubclinical or recurrent varicoceles, normal semen parameters, azoospermia

For pelvic/labial varicosities, document ADL impairment, failed ≥3 months conservative therapy including prescription anti-inflammatories, and vein diameter ≥4 mm

Prior Authorization

Penile implants require benefit rider and prior therapy documentation

Penile implant coverage requires that the member's plan includes a sexual dysfunction rider and that appropriate covered medical therapies have been tried and failed; replacements require documentation of malfunction, infection, or breakage and continued medical necessity.

Verify member has sexual dysfunction rider before requesting authorization
Document prior trials of covered medical therapies and indications for replacement when applicable

Prior Authorization

Percutaneous renal nerve ablation is not covered

Percutaneous renal nerve ablation (CPT 0338T, 0339T) is considered investigational and is not covered by Select Health Commercial/CHIP; verify member contract for appeal or exceptions per benefit.

Do not submit authorization requests for renal denervation under Commercial/CHIP — claims at risk of denial
Consult member contract and CMS/medical policy for Medicare applicability

Prior Authorization

Prior authorization for PTNS — initial weekly 12‑week course

PTNS (percutaneous) is covered only when all listed PTNS criteria are met; initial treatments are authorized weekly for 12 weeks and continuation requires documented response per policy.

Ensure documentation of OAB duration ≥12 months and prior medication/behavioral therapy trials
Initial weekly PTNS treatments limited to a 12-week course

Billing Rule

PTNS treatment limits, response requirement, and retreatment interval

Initial PTNS is covered as a 12-week weekly course; maintenance and retreatment are limited — maintenance coverage requires documented ≥50% symptom improvement and retreatment after the initial course is restricted by a 24‑month interval unless symptoms recur.

Initial course: weekly for 12 weeks
Maintenance: covered every 1–2 months for the remainder of the year only if ≥50% symptom improvement is documented
Retreatment after initial 12 months not covered unless ≥24 months have elapsed since completion and symptoms have returned

Note

Coverage and prior auth determinations vary by plan; Medicare follows CMS

Coverage determinations (including TLV, TLV-related codes, and others) vary by plan; Medicare follows CMS determinations where applicable — verify benefit specifics and obtain prior authorization as required.

For Medicare members, consult CMS coverage database; if CMS has no determination, the Select Health Commercial policy may apply
Verify prior authorization requirements per member plan

Prior Authorization

Verify member benefits and obtain prior authorization as required

Providers must verify the member's benefits and obtain any required prior authorization with Select Health before performing services; coverage and preauthorization requirements depend on the individual benefit plan.

Contact Provider Relations or Customer Service for benefit verification and questions
Do not assume coverage based on policy text alone—confirm member-specific benefits

Prior Authorization

UroLift requires prior authorization with documented age, prostate size, and failed conservative therapy

UroLift (prostatic urethral lift) coverage requires prior authorization documenting the patient's age (>45), prostate volume (<100 cc), and failure of ≥3 months of conservative therapy (including trials of both an alpha‑1 antagonist and a 5‑alpha‑reductase inhibitor) or documented intolerance/contraindication to medical therapy.

Include prostate volume measurement and documentation of ≥3 months conservative therapy in the authorization request
If >7 implants are planned, supply clinical justification; second procedures require explanation why other prostate removal procedures are not indicated

Prior Authorization

Verify benefits — coverage depends on individual plan

Coverage of many procedures (UroLift, varicocele treatments, embolization, etc.) depends on the member's individual benefit plan; providers should verify benefits and obtain prior authorization when required.

Verify member-specific coverage before scheduling procedures
Obtain prior authorization when the plan requires it

Billing Rule

Varicocele procedure codes — verify prior authorization and member coverage

Codes related to varicocele embolization and surgical varicocelectomy are listed for informational purposes; coverage depends on the member's contract and prior authorization must be verified.

Listed CPT codes include 37241, 55530, 55535, 55540, 55550
Confirm medical necessity and plan-specific prior authorization before billing

Prior Authorization

Preauthorization depends on member benefits — confirm before service

Policy coding is informational; whether preauthorization is required depends on the member's contract — providers must refer to the benefit plan to determine preauthorization needs.

Do not rely on code lists alone to determine coverage
Contact Provider Relations for plan-specific preauthorization rules

Note

Optilume among endoscopic options — no explicit step‑therapy mandated

Optilume is positioned among endoscopic options (e.g., dilation, DVIU, urethroplasty) but the policy does not specify an explicit step‑therapy sequence requiring prior procedures before using Optilume.

Document prior treatments when relevant, but no mandatory stepwise sequence is defined in this excerpt

Step Therapy

Require ≥3 months of conservative therapy before intervention

Prior to procedural coverage, members must have failed at least 3 months of conservative therapy (including prescription anti‑inflammatories unless contraindicated) as specified in the applicable criteria.

Document the ≥3 months duration and therapies attempted in the medical record and authorization request

Step Therapy

Penile implant is third‑line — document failure of less invasive therapies

Penile prosthesis is considered a third‑line therapy and should be reserved for patients who have failed less invasive treatments such as PDE5 inhibitors, intra‑urethral alprostadil, intracavernous injections, or vacuum devices.

Document prior less‑invasive treatment trials in the medical record and authorization materials

Documentation Required

Document prior medical therapy for resistant hypertension before investigational procedures

For procedures addressing resistant hypertension, the policy references prior medical therapy definitions (resistant hypertension defined as failure of an appropriate 3‑drug regimen including a diuretic) before considering investigational procedures.

Ensure documentation of prior antihypertensive regimen adherence and BP goals when applicable

Step Therapy

Medication trial requirement before PTNS (4–6 week trials)

For PTNS coverage, the patient must have tried at least two different anticholinergic drugs, or an anticholinergic plus a tricyclic drug for 4–6 weeks without improvement, or document intolerance, before PTNS is authorized.

Document medication names, durations (4–6 weeks), and response or intolerance in the record

Billing Rule

Only specified synthetic bulking agents are covered

Select Health covers specific synthetic bulking agents (Durasphere, Coaptite, Macroplastique, Bulkamid); other synthetic bulking agents are considered investigational and are not covered.

Use covered products only; alternative agents listed as investigational should not be billed as covered

Note

TLV covered when criteria met; follow CMS/InterQual for Medicare

TLV is covered when criteria are met; Medicare follows CMS or InterQual determinations where applicable — consult the applicable criteria for authorization decisions.

Note

Consider surgery after conservative therapy failure; RF approaches may be investigational

Surgery may be considered after failure of conservative therapies; radiofrequency approaches are presented as minimally invasive alternatives but are not covered when considered investigational.

Document failure of conservative measures prior to surgical consideration

Step Therapy

Document failure of ≥3 months conservative BPH therapy before UroLift

Members must have failed ≥3 months of conservative therapy — specifically failure of both an alpha‑1‑adrenergic antagonist and a 5‑alpha‑reductase inhibitor — before UroLift coverage, unless intolerant or contraindicated.

Document medication names, durations, and reasons for intolerance or contraindication if applicable

Note

Plan-specific sequence: Community Care aligns with Utah Medicaid; Medicare follows CMS

Select Health Community Care (Medicaid) typically aligns with Utah Medicaid and may use InterQual; Medicare coverage follows CMS determinations — verify which criteria source applies for the member.

Consult Utah Medicaid manuals or CMS database as appropriate for beneficiary type

Note

No explicit mandated step‑therapy sequence specified

While the policy discusses comparative evidence for treatments (e.g., embolization vs ligation), no explicit mandatory step‑therapy sequence is specified for most interventions in this excerpt.

Note

Criteria revisions can affect prior authorization/sequencing

Revisions to criteria (for example to criterion B) may change prior authorization or sequencing requirements for commercial plan members; check the policy revision history when submitting authorizations.

Review revision history and use the current policy version when preparing prior authorization requests

Documentation Required

Document clinical criteria and stricture characteristics for coverage

Coverage requires documentation that the listed clinical criteria and stricture characteristics are met; include relevant clinical findings and prior treatment history in the authorization request.

Attach history, physical findings, imaging, and documentation of prior therapies to support coverage

Documentation Required

Required documentation for pelvic vein procedure coverage

For pelvic vein procedures, documentation must show pelvic pain ≥6 months, imaging consistent with pelvic venous changes, and failed conservative therapy of ≥3 months including prescription anti‑inflammatories, or for pelvic/labial varicosities document ADL impairment, failed ≥3 months conservative therapy, and vein diameter ≥4 mm.

Include imaging reports and records of conservative therapy attempts with dates and medications

Documentation Required

Document history, prior therapy trials, and device issues for penile implant requests

Providers must document history and physical consistent with sexual dysfunction and prior trials of appropriate covered medical therapies when requesting penile implant coverage; include device issue details for replacements.

Document prior medical therapies tried/failed and details of device malfunction, infection, or breakage for replacements

Documentation Required

Pre‑service benefit verification and contact information

Verify member benefits and eligibility prior to service; providers may contact Provider Relations at (801) 442-3692 or instruct members to contact Customer Service for benefit questions.

Confirm coverage, prior authorization requirements, and any rider applicability before scheduling

Documentation Required

Required clinical documentation for PTNS (≥12 months symptoms and prior trials)

PTNS requires documentation that OAB symptoms have persisted for ≥12 months, prior medication trials and behavioral therapies were attempted, and that symptoms limit ADLs before authorization.

Include medication trial details (names, durations), behavioral therapy attempts, and ADL impact in the record

Documentation Required

Document ≥50% symptom improvement for PTNS maintenance coverage

For maintenance PTNS coverage after the initial course, providers must document a ≥50% improvement in OAB symptoms to qualify for maintenance treatments every one to two months for the remainder of the year.

Note

Verify benefits and contact for questions

Providers should contact Customer Service or Provider Relations for benefit/eligibility questions and to confirm prior authorization requirements before delivering services.

Provider Relations: (801) 442-3692
Members: call the number on their ID card for benefit specifics

Note

Recommend benefit verification prior to services

Benefit verification is recommended — providers should review the member's individual benefit plan and contact Customer Service or Provider Relations for eligibility/benefit verification prior to service.

Documentation Required

Documentation required to support UroLift prior authorization

UroLift prior authorization must include clinical documentation supporting prostate volume <100 cc, patient age >45, and failure of ≥3 months of conservative therapy (including trials of both an alpha‑1 antagonist and a 5‑alpha‑reductase inhibitor) or documentation of intolerance/contraindication.

Documentation Required

Documentation needed for varicocele treatment coverage

Documentation to support varicocele treatment must show one of the surgical coverage indications (adolescent testicular growth retardation with grade 2–3 varicocele, scrotal pain, or male infertility with impaired semen parameters) or post‑surgical recurrence, with supporting evidence.

Include semen analysis, physical exam grade, growth/ pain history, or operative reports as applicable

Note

Policy alignment — consult Utah Medicaid/InterQual for Community Care members

Select Health Community Care policies typically align with Utah Medicaid; providers should consult Utah Medicaid manuals and the member's contract benefits for coverage determinations when applicable.

Use InterQual or Utah Medicaid resources where indicated for Medicaid members

Documentation Required

Verify benefits and contact Provider Relations for authorization questions

Providers should verify member benefits and eligibility prior to service and may contact Provider Relations at (801) 442-3692 for questions about coverage or authorization.

Denial Risk

Denial risk if required clinical criteria are not documented

Requests that do not include required documentation (for example, pelvic pain ≥6 months and imaging consistent with pelvic venous changes for PCS) may be denied for failure to meet documented criteria.

Ensure all listed clinical criteria are clearly documented in the request to avoid denial

Denial Risk

Penile implant coverage limited to plans with sexual dysfunction rider

Penile implants are not a standard covered benefit for commercial plans unless the member has a sexual dysfunction rider and meets the stated criteria; lack of a rider or unmet criteria may result in denial.

Verify rider presence and document criteria to support coverage

Denial Risk

Renal denervation claims are at risk of denial (not covered)

Percutaneous renal nerve ablation is not covered by Select Health and is at risk of denial as investigational for Commercial and CHIP members.

Denial Risk

PTNS not covered as first‑line therapy

PTNS performed as first‑line therapy for OAB is not covered and may be denied; ensure prior medication and behavioral therapy trials are documented before requesting PTNS.

Denial Risk

PTNS stopping rule — no improvement after 6 sessions

If a patient fails to improve after 6 PTNS treatments, continued treatment is considered not medically necessary and is at risk of denial.

Denial Risk

PTNS retreatment restricted to ≥24 months after initial course

Continued PTNS treatment after the initial course is not covered unless 24 months have elapsed since completion of the initial PTNS treatment and symptoms have returned; without meeting this interval, retreatment requests may be denied.

Note

Code listing does not guarantee coverage or reimbursement

Inclusion or exclusion of procedure/diagnosis codes in the policy does not guarantee member coverage or provider reimbursement; benefits are determined by the member's contract and eligibility at time of service.

Denial Risk

Transurethral RF for SUI is not covered (NMN)

Transurethral radiofrequency (RF) procedures for stress urinary incontinence (e.g., Renessa) are considered not medically necessary and are not covered; billing for these services for SUI may be denied.

Documentation Required

Requests >7 UroLift implants require justification

Requests recommending more than 7 UroLift implants require clinical documentation justifying medical necessity; absence of such justification may result in denial.

Documentation Required

Justify second UroLift procedure vs other prostate procedures

A second UroLift (repeat) procedure requires an explanation of why other prostate removal procedures are not clinically indicated; without this justification, the request may be denied.

Denial Risk

Varicocele treatment for subclinical cases and endoluminal devices not covered

Surgical treatment for subclinical varicocele is considered experimental/investigational and is not covered; use of endoluminal occlusion devices for varicoceles is also not covered.

Prior Authorization

Benefit verification required before services

Verify member benefits prior to service — coverage determinations are made according to the member's individual benefit plan in effect at the time of service.

Denial Risk

Coverage depends on member's contract — risk of eligibility‑dependent denials

Coverage and eligibility are determined by the member's individual benefit plan at the time of service; inclusion/exclusion of codes in this policy does not, by itself, prevent denials if the member's contract does not cover the service.

Pelvic congestion syndrome (PCS)

DefinitionPelvic congestion syndrome (PCS): visibly engorged pelvic veins >10 mm on selective transuterine venography in multiparous premenopausal women with chronic noncyclic pelvic pain >6 months

Imaging threshold>10 mm venous diameter on selective transuterine venography

Associated featuresSymptoms worse when standing, during/after intercourse, and may be associated with vulvar/leg varices and bladder urgency

Penile implants

Penile implant typesThree types: semi-rigid (malleable), two-piece inflatable, and three-piece inflatable

PurposeImplanted devices to allow erection for men with erectile dysfunction

Clinical contextConsidered after failure of less invasive therapies; covered only with appropriate plan rider and documentation

Index case of ED

Index case of EDAbsence of hypogonadism or hyperprolactinemia in a man who develops, after a period of normal erectile function, erectile dysfunction that is primarily organic in nature

Definition sourceAmerican Urological Association (AUA) guideline definition

Clinical useUsed to characterize patients for treatment pathway decisions

Resistant hypertension

Resistant hypertension definitionFailure to achieve goal blood pressure despite adherence to an appropriate 3-drug regimen including a diuretic

Typical BP goalUsually <140/90 mmHg (or <130/80 mmHg in diabetes, proteinuric CKD, or coronary disease)

ImplicationDefines population considered for investigational procedures like renal denervation

Percutaneous renal nerve ablation

DefinitionCatheter-based radiofrequency ablation of renal sympathetic nerves via the renal artery

Procedure descriptionRF energy applied at multiple timed applications while rotating catheter along renal artery to ablate sympathetic fibers

Intended effectLower systemic blood pressure by disrupting renal sympathetic efferent and afferent signaling

PTNS

DefinitionPercutaneous posterior tibial nerve stimulation (PTNS): insertion of a needle above the medial malleolus to apply low-voltage electrical stimulation to the posterior tibial nerve

Procedure detailsTypically 30-minute sessions weekly for 12 weeks; stimulation 10 mA, 1–10 Hz producing sensory and motor responses; maintenance intervals vary

Coverage contextInitial course covered weekly for 12 weeks; maintenance requires documented >=50% symptom improvement

Overactive bladder (OAB)

Definition of OABUrgency with or without urge incontinence, usually with frequency and nocturia causing bladder storage dysfunction

Clinical featuresMay include incontinence episodes; behavioral and pharmacologic therapy are first-line

RelevanceDefines condition for PTNS coverage criteria in policy

Periurethral bulking agents

DefinitionPeriurethral bulking agents: substances injected into submucosal tissues of the urethra and/or bladder neck to increase tissue bulk and treat stress urinary incontinence (often for intrinsic sphincter deficiency)

Intended useImprove urethral coaptation and reduce stress urinary incontinence symptoms; may require repeat injections due to absorption of some materials

ExamplesCrosslinked collagen, carbon-coated beads (Durasphere); other agents may be investigational

Intrinsic sphincter deficiency (ISD)

Intrinsic sphincter deficiency (ISD)A cause of stress urinary incontinence for which bulking agents are used

Clinical implicationPatients with ISD may be candidates for periurethral injection to improve urethral resistance

Relation to bulking agentsISD is the primary indication for periurethral bulking injections

Periurethral injection (urethral bulking)

Procedure definitionInjection of bulking agents into submucosal tissues of the urethra/bladder neck to improve coaptation and reduce stress urinary incontinence

Treatment courseMay require multiple injections to achieve effect; durability varies by agent

Evidence noteRandomized trials show short-term benefit but long-term efficacy and durability are less certain

Transurethral laser vaporization (TLV)

DefinitionTransurethral laser vaporization (TLV): a contact laser technique that vaporizes prostate tissue to create a wide channel for obstructive BPH

Clinical contextUsed for obstructive BPH in patients who fail medical therapy; generally applicable for prostates up to ~120 cc

Coding noteCPT 52648 listed for laser vaporization of prostate

Transurethral radiofrequency (RF) for SUI (Renessa)

DefinitionTransurethral radiofrequency (RF) for SUI (Renessa): a transurethral procedure using RF energy to heat tissue and denature collagen at multiple small sites, increasing tissue firmness to reduce SUI

MechanismControlled heating causes collagen remodeling and tissue firming without gross tissue destruction

Coverage stancePolicy notes insufficient evidence; considered not medically necessary for SUI

UroLift (Prostatic urethral lift)

Device definitionUroLift (prostatic urethral lift): transprostatic permanent implants placed to hold enlarged prostate tissue away from the urethra

MechanismMechanical separation of prostatic lobes using implants delivered transurethrally to relieve LUTS while preserving sexual function

Typical implants usedAverage procedure uses ~4 implants (manufacturer ~4.9); literature reports mean <4 with range 2–7

Clinical BPH / BPH-LUTS

Clinical BPH / BPH-LUTSBenign prostatic hyperplasia causing lower urinary tract symptoms significant enough to require therapy

DiagnosisBased on clinical history, DRE, focused urologic exam, and urinalysis; PSA may aid evaluation

RelevanceDefines patient population for procedures like TLV and UroLift

Varicocele grades

Varicocele gradesGrade 1: palpable only with Valsalva; Grade 2: palpable without Valsalva; Grade 3: visible

Clinical useGrades used to determine treatment indications in adolescents and infertile men

PrevalenceFound in 10–15% of males; ~30% in men with impaired fertility

UroLift indication (per NICE summary)

Suggested UroLift patient profile (NICE)Men aged 50+ with prostate <100 ml and no obstructing middle lobe

Intended useAlternative to standard surgery in day-case settings to relieve LUTS while preserving sexual function

Evidence noteData show improvements in symptoms and QoL but some patients require revisions at longer follow-up

Subclinical varicocele

Subclinical varicoceleA varicocele not palpable on physical examination

Evidence/controversyManagement and benefit from treating subclinical varicocele remain controversial with low-quality evidence and no clear pregnancy-rate benefit

Coverage stanceSurgical treatment for subclinical varicocele considered experimental/investigational and not covered

Endoluminal occlusion device (ArtVentive EOS)

Device descriptionEndoluminal occlusion device (ArtVentive EOS): implantable occlusion device plus delivery catheter available in sizes for target vessels 3.5–8.5 mm

SizingSize 1 for vessels 3.5–5.5 mm; Size 2 for vessels 5.5–8.5 mm

Clinical findingsInitial small series showed 100% acute occlusion and short-term patency at 30 days; further studies limited

Added exclusion: Optilume is not covered for treatment of any other indication, including but not limited to benign prostatic hyperplasia (BPH).

2025-05-02added

Added exclusion: Select Health does not cover wearable neuromodulation systems (e.g., Vivally, ZIDA) as effectiveness has not been established.

2024-12-11revised

Expanded exclusion language to cover leadless neuromodulation systems (e.g., BlueWind Revi, eCoin, Freedom) as experimental/investigational due to safety concerns and lack of long-term outcomes.

2024-06-03added

Added Bulkamid to the list of synthetic periurethral bulking agents eligible for coverage.

2024-06-12revised

Modified PTNS treatment limitations: specified initial weekly 12-week course, stopping rule after 6 treatments, retreatment interval and documentation requirements.

2023-12-14revised

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

2023-11-07revised

Modified criteria for varicocele treatment criteria #B to include 'Meets one of the above criteria for surgery OR post-surgical (ligation) recurrence of varicoceles.'

The documented revision to criteria B (noted 11/7/23) may change prior authorization or sequencing requirements for commercial plan members. Specifically, the revision clarifies that coverage under criteria B can be met either by meeting one of the surgery criteria or by demonstrating post-surgical (ligation) recurrence of varicoceles, which could affect how requests are authorized and documented.