CurrentUnitedHealthcarePolicy CS334LA.F

Prostate Surgeries and Interventions (for Louisiana Only)

Defines medical necessity and non-coverage positions for a range of prostate surgeries and minimally invasive interventions for benign prostatic hyperplasia and prostate cancer for UnitedHealthcare members in Louisiana, with references to InterQual criteria for specific procedures and an applicable code list.

Policy Summary

PayerUnitedHealthcare

PolicyProstate Surgeries and Interventions (for Louisiana Only)

Policy CodePolicy CS334LA.F

Change TypeCoverage criteria updates; CPT code additions/removals

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionFor transurethral ablation and cryoablation, providers must refer to and document that the patient meets InterQual CP criteria referenced in the policy to support medical necessity.

POLICY UPDATE CHANGES

Removed coverage criteria for transperineal placement of biodegradable material.

Revised coverage criterion for prostatic urethral lift to include 'including lateral, with or without median lobe hyperplasia, in men 45 years of age or older.'

Revised transurethral water jet ablation language to specify it is unproven and not medically necessary for malignant prostate tissue and all other indications not listed as proven.

Revised PAE coverage wording to specify proven and medically necessary for individuals with BPH who are ineligible for other procedures due to surgical constraints or anesthesia risk.

Added 'transurethral thermal ultrasound ablation (TULSA)' to the list of unproven and not medically necessary procedures.

Added CPT codes 51721, 53865, 53866, 55881, and 55882 to the policy's applicable codes.

Removed CPT code 55874 from the policy's applicable codes.

Updated non-substantive sections (Description of Services, Clinical Evidence, FDA, and References) for currency (clarifications).

MultipleProcedures addressed

Louisiana

Coverage Summary

Scope: This policy defines medical necessity and non-coverage positions for a range of prostate surgeries and minimally invasive prostate interventions for UnitedHealthcare members in Louisiana only, with specific dependency on InterQual clinical criteria for certain procedures. The policy is effective 2025-08-01 and lists applicable CPT/HCPCS codes (including recently added codes) for reference; note some listed codes are not on the State of Louisiana Medicaid Fee Schedule and may not be covered by that program.

Coverage stance (mixed): The policy designates specific procedures as proven and medically necessary when InterQual or FDA-labeled criteria are met (for example, transurethral ablation and cryoablation when InterQual CP criteria are satisfied; prostatic urethral lift when FDA labeled indications and contraindication checks are met). Other procedures are explicitly listed as unproven and not medically necessary for all other indications (see list of investigational procedures including TPLA and TULSA). The policy intent is to define medical necessity positions, require documentation of InterQual criteria or FDA indications where specified, and to reference InterQual dependency for coverage decisions.

Key thresholds & quick facts

PUL age threshold>= 45 years

PUL prostate volume contraindication> 100 cc (contraindicated)

PAE notable retreatment stat21% required TURP within 2 years (Abt RCT)

CPT code changes (count)5 codes added (51721, 53865, 53866, 55881, 55882); 1 removed (55874)

Newly listed unproven procedureTransurethral thermal ultrasound ablation (TULSA) added to unproven/not medically necessary list

Medical Necessity Criteria (by procedure)

Transurethral Ablation

Transurethral ablation of the prostate is proven and medically necessary when it meets InterQual clinical criteria. Rendered below are the high-level coverage determinations.

operator: any label: "Transurethral Ablation" children: [ { "operator": "all", "label": "Meets InterQual criteria", "children": [ { "text": "Meets the InterQual® CP: Procedures, Prostatectomy, Transurethral Ablation clinical criteria for the requested indication (see InterQual for specific clinical elements)." } ] }, { "operator": "all", "label": "Not covered when", "children": [ { "text": "Requested for indications that do not meet InterQual criteria or for all other indications due to insufficient evidence of safety and/or efficacy (unproven/not medically necessary).", "note": "Provider should document rationale and prior authorization may be required." } ] } ]

Cryoablation

Cryoablation of the prostate is covered for recurrent prostate cancer when biopsy-proven disease and InterQual procedural criteria are met. It is not covered for initial treatment or other indications.

operator: any label: "Cryoablation" children: [ { "operator": "all", "label": "Covered — recurrent prostate cancer", "children": [ { "text": "Biopsy-proven recurrent prostate cancer and the procedure meets InterQual® CP: Procedures, Cryoablation, Prostate clinical criteria." } ] }, { "operator": "all", "label": "Not covered when", "children": [ { "text": "Requested as initial definitive treatment for prostate cancer or for any other indication not supported by InterQual — unproven and not medically necessary due to insufficient evidence of safety and/or efficacy." } ] } ]

Evidence Summaries and Coverage Implications

Evidence across procedures is heterogeneous: multiple randomized trials, systematic reviews, and technology assessments are cited, but results vary by intervention and are commonly limited by small sample sizes, clinical and methodological heterogeneity, and relatively short follow-up in many studies.

Key limitations that recur across the evidence base include study heterogeneity (different populations, endpoints, and comparators), limited long-term follow-up for durability and oncologic endpoints (particularly for focal/whole-gland ablation and newer devices), modest sample sizes or single-arm designs, and loss to follow-up in some trials. These limitations constrain confidence in comparative effectiveness versus established treatments such as TURP or radical therapies.

How evidence informs coverage: where InterQual or FDA-labeled indications and contraindication checks exist and reasonable evidence supports benefit, procedures are covered (for example, transurethral ablation and cryoablation when InterQual criteria are met; PUL when FDA labeled indications/contraindications are satisfied). For PAE the evidence suggests symptomatic improvement versus baseline but potentially less improvement on some functional measures and higher retreatment rates versus TURP (reported 21% retreatment in one RCT), so the policy limits PAE to patients who are ineligible for other procedures due to surgical constraints or anesthesia risk or for persistent prostatic gross hematuria. For procedures with insufficient/early evidence (TPLA/FLA, temporary urethral stents, TULSA, magnetic nanoparticle ablation, transurethral drug-coated balloon in some contexts), the policy treats these as investigational or not medically necessary or limits them to clinical trials/registries until better evidence is available.

Coverage conclusions and clinical appropriateness (inferred from evidence summaries)

Coverage and clinical appropriateness depend on comparative effectiveness and evidence quality; summarized conclusions from multiple systematic reviews and trials:

Coding

Referenced CPT/HCPCS codes (listed for reference; inclusion does not imply coverage)mixed

0421T	Transurethral waterjet ablation of prostate, including control of post-operative bleeding, including ultrasound guidance, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when performed).
0582T	Transurethral ablation of malignant prostate tissue by high-energy water vapor thermotherapy, including intraoperative imaging and needle guidance.
0619T	Cystourethroscopy with transurethral anterior prostate commissurotomy and drug delivery, including transrectal ultrasound and fluoroscopy, when performed.
0655T	Transperineal focal laser ablation of malignant prostate tissue, including transrectal imaging guidance, with MR-fused images or other enhanced ultrasound.
0714T	Transperineal laser ablation of benign prostatic hyperplasia, including imaging guidance; prostate volume less than 50mL.
0738T	Treatment planning for magnetic field induction ablation of malignant prostate tissue, using data from previously performed MRI examination.
0739T	Ablation of malignant prostate tissue by magnetic field induction, including intraprocedural nanoparticle installation and monitoring.
0867T	Transperineal laser ablation of benign prostatic hyperplasia, including imaging guidance; prostate volume greater or equal to 50mL.
37243	Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation ... (when performed on prostate tissue).
51721	Insertion of transurethral ablation transducer for delivery of thermal ultrasound for prostate tissue ablation, including suprapubic tube placement during the same session and placement of an endorectal cooling device, when performed.

1–10 of 21

1/3

No procedure or diagnosis codes specified in this excerptmixed

No codes listed

FDA-cleared/approved devices mentionedmixed

UroLift (K193269)	UroLift System 510(k) clearance for treatment of LUTS due to BPH (includes lateral and median lobe) - informational
Rezūm (K191505)	Rezūm Water Vapor Therapy 510(k) clearance for BPH LUTS including median lobe - informational
Spanner (PMA P060010)	Spanner Temporary Prostatic Stent PMA (2006) - informational
iTind (K210138)	iTind temporary implantable nitinol device 510(k) clearance (June 2021) - informational
Aquabeam (K202961)	Aquabeam Robotic System 510(k) for resection/removal of prostate tissue (March 3, 2021) - informational
Optilume (PMA P220029A)	Optilume Urethral Drug Coated Balloon PMA (June 30, 2023) - informational

Added CPT codes (08/01/2025)CPT

51721	Insertion of transurethral ablation transducer for delivery of thermal ultrasound for prostate tissue ablation...
53865	Cystourethroscopy with insertion of temporary device for ischemic remodeling (ie, pressure necrosis) of bladder neck and prostate.
53866	Catheterization with removal of temporary device for ischemic remodeling (ie, pressure necrosis) of bladder neck and prostate.
55881	Ablation of prostate tissue, transurethral, using thermal ultrasound, including MRI guidance for, and monitoring of, tissue ablation.
55882	Ablation of prostate tissue, transurethral, using thermal ultrasound, including MRI guidance for, and monitoring of, tissue ablation; with insertion of transurethral ultrasound transducer for delivery of thermal ultrasound, including suprapubic tube placement and placement of an endorectal cooling device, when performed.

Removed CPT codes (08/01/2025)CPT

55874

Documentation Required

Verify coverage for selected CPT codes (Louisiana Medicaid may not cover)

Verify coverage when billing CPT codes 51721, 53865, 53866, 55881, and 55882. These codes are listed in the policy's Applicable Codes section and are marked as not on the State of Louisiana Medicaid Fee Schedule; they therefore may not be covered by the State of Louisiana Medicaid Program. Confirm the member's specific plan and state Medicaid fee schedule before billing.

Check the State of Louisiana Medicaid Fee Schedule prior to claim submission.
Obtain prior authorization or medical necessity confirmation if required by the payer.
Document the procedure, indication, and relevant clinical criteria to support coverage determination.

Provider Actions and Authorization Guidance

Documentation Required

Reference InterQual criteria

Providers must refer to the InterQual CP criteria identified in the policy and document that the patient meets those InterQual clinical criteria to support medical necessity for transurethral ablation and for cryoablation (as applicable).

Reference the specific InterQual CP: Procedures, Prostatectomy, Transurethral Ablation for transurethral ablation.
Reference InterQual CP: Procedures, Cryoablation, Prostate for cryoablation.
Include documentation showing how the patient satisfies each InterQual element used to justify the procedure.

Documentation Required

Confirm FDA labeled indications/contraindications for PUL

Confirm and document that PUL (prostatic urethral lift) is being performed according to FDA-labeled indications and that none of the listed contraindications are present. Required exclusions to document include prostate volume greater than 100 cc, current urinary tract infection, urethral conditions that would prevent insertion of the delivery system into the bladder (per Instructions for Use), urinary incontinence due to an incompetent sphincter, and current gross hematuria.

Definitions

Term	Definition
LUTS
Lower urinary tract symptoms
BPH
Benign prostatic hyperplasia
IPSS
International Prostate Symptom Score; a patient-reported measure of urinary symptoms.
Qmax
Maximum urinary flow rate; peak urinary flow rate in mL/sec.
PVR
Post-void residual volume; post-void residual urine volume.
TURP
Transurethral resection of the prostate

Revision History (policy changes)

2025-08-01MaterialLatest

Removed coverage criteria for transperineal placement of biodegradable material.

2025-08-01MaterialLatest

Revised coverage criterion for prostatic urethral lift to include 'including lateral, with or without median lobe hyperplasia, in men 45 years of age or older.'

2025-08-01Material

Policy Summary

PayerUnitedHealthcare

PolicyProstate Surgeries and Interventions (for Louisiana Only)

Policy CodePolicy CS334LA.F

Change TypeCoverage criteria updates; CPT code additions/removals

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionFor transurethral ablation and cryoablation, providers must refer to and document that the patient meets InterQual CP criteria referenced in the policy to support medical necessity.

On This Page

Prostatic Urethral Lift (PUL)

Prostatic urethral lift (PUL, e.g., UroLift®) is covered only when performed within FDA-labeled indications and when specified exclusion criteria are absent.

operator: all label: "Prostatic Urethral Lift (PUL)" children: [ { "operator": "all", "label": "Required FDA-labeled indications", "children": [ { "text": "Treating symptoms due to urinary outflow obstruction secondary to benign prostatic hyperplasia (BPH), including lateral lobes, with or without median lobe hyperplasia.", "threshold": "Age ≥ 45 years" }, { "text": "Performed in men 45 years of age or older." } ] }, { "operator": "all", "label": "None of the following are present (Exclusion criteria)", "children": [ { "text": "Prostate volume > 100 cc", "note": "Prostate volume threshold per FDA labeling." }, { "text": "Active urinary tract infection" }, { "text": "Urethral conditions preventing insertion of the delivery system into the bladder (anatomic or strictures)" }, { "text": "Urinary incontinence due to incompetent sphincter" }, { "text": "Current gross hematuria" } ] }, { "operator": "all", "label": "Not covered when", "children": [ { "text": "Indication is outside FDA-labeled use or any of the exclusion criteria above are present — unproven and not medically necessary." } ] } ]

High-Energy Water Vapor Thermotherapy

High-energy water vapor thermotherapy (e.g., Rezūm™) for BPH is covered when InterQual criteria for BPH treatment are met. Treatment of malignant prostate tissue or other non-BPH indications is not covered.

operator: any label: "High-Energy Water Vapor Thermotherapy" children: [ { "operator": "all", "label": "Covered when", "children": [ { "text": "Meets InterQual® CP criteria for treatment of benign prostatic hyperplasia (BPH) for the requested procedure." } ] }, { "operator": "all", "label": "Not covered when", "children": [ { "text": "Requested for treatment of malignant prostate tissue or for other indications not supported by InterQual — unproven and not medically necessary due to insufficient evidence." } ] } ]

Transurethral Water Jet Ablation

Transurethral water jet ablation (e.g., Aquabeam®) is covered for resection/removal of prostate tissue to treat LUTS due to BPH. Use for malignant tissue or other unsupported indications is not covered.

operator: any label: "Transurethral Water Jet Ablation" children: [ { "operator": "all", "label": "Covered when", "children": [ { "text": "Requested for resection and removal of prostate tissue for treatment of lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH), with intent to remove/resect tissue." } ] }, { "operator": "all", "label": "Not covered when", "children": [ { "text": "Requested for treatment of malignant prostate tissue or for other indications not supported by evidence — unproven and not medically necessary." } ] } ]

Prostate Artery Embolization (PAE)

Prostate artery embolization (PAE) is covered selectively for BPH when other procedures are infeasible or for persistent gross hematuria from the prostate. It is not covered for other indications.

operator: any label: "Prostate Artery Embolization (PAE)" children: [ { "operator": "any", "label": "Covered when ANY of the following are met", "children": [ { "text": "Patient with BPH who is ineligible for other standard procedures due to surgical constraints (for example, prostate size) or anesthesia risk related to comorbidities.", "note": "Suitability should be determined by the treating physician; documentation must explain why standard surgical or minimally invasive options are not appropriate." }, { "text": "Persistent gross hematuria originating from the prostate despite conservative measures." } ] }, { "operator": "all", "label": "Not covered when", "children": [ { "text": "Requested for indications other than those listed above — unproven and not medically necessary due to insufficient evidence of safety and/or efficacy." } ] } ]

Other Procedures (Unproven / Not Medically Necessary)

The procedures below are considered unproven and not medically necessary for all indications due to insufficient evidence of safety and/or efficacy.

operator: any label: "Other Procedures (Unproven / Not Medically Necessary)" children: [ { "text": "Transperineal focal laser ablation (including focal laser ablation/FLA)", "note": "Not medically necessary for all indications." }, { "text": "Insertion of a temporary prostatic urethral stent", "note": "Not medically necessary for all indications." }, { "text": "Transperineal laser ablation (TPLA)", "note": "Not medically necessary for all indications." }, { "text": "Ablation of malignant prostate tissue by magnetic field induction", "note": "Not medically necessary for all indications." }, { "text": "Transurethral drug coated balloon dilation", "note": "Not medically necessary for all indications." }, { "text": "Transurethral thermal ultrasound ablation (TULSA)", "note": "Not medically necessary for all indications." } ]

PAE evidence summary: PAE may improve patient-reported outcomes vs baseline but may be less effective than TURP for many functional outcomes; higher retreatment rates (eg, 21% requiring TURP within 2 years in one RCT) and uncertainty regarding adverse events; consider for patients who are poor surgical candidates or refuse surgery

Multiple RCTs and systematic reviews; low-to-moderate certainty

TPLA/FLA evidence summary: Evidence insufficient to support long-term effectiveness and safety; RCTs show inferiority to TURP on efficacy but superiority for preservation of ejaculation; overall low-quality evidence; recommend limiting use to clinical trials

Several small RCTs and systematic reviews

Temporary stents evidence summary: Evidence limited and inconclusive; some RCTs and observational studies show short-term symptom improvement and acceptable safety in selected patients, but generalizability limited; further comparative research needed

Mixed RCT and observational data

Use-case recommendations: Consider PAE for BPH/LUTS patients who are poor candidates for surgery or anesthesia or refuse surgery after counseling about higher retreatment rates and potentially inferior functional outcomes vs TURP; TPLA/FLA should be investigational for oncologic control and limited to trials; temporary urethral stents may be investigational/conditional

Recommendations inferred from evidence summaries and guidelines

Guideline and device synthesis: Major guideline bodies (AUA, EAU, NICE, SIR, NCCN and joint AUA/ASTRO statements) provide conditional or specified support for selected minimally invasive procedures in defined patient groups and prostate size/anatomy ranges. Guidelines generally support PUL, water vapor therapy, aquablation, and PAE in certain patients while cautioning that focal or whole-gland ablation approaches should be done in trials or with informed counseling about limited comparative data for oncologic outcomes.

Device-specific takeaways to guide clinical interpretation: UroLift/PUL is supported within its FDA-labeled indications (including lateral lobes and median lobe considerations) for appropriately sized prostates; Rezūm (water vapor) and Aquablation have guideline-supported roles for selected prostate size ranges but longer-term retreatment data remain limited; PAE is endorsed by some bodies for selected patients (including those with large glands or poor surgical candidacy) but comparative data show higher retreatment and variable functional outcomes versus TURP; focal/thermal whole-gland ablation technologies such as TULSA and transperineal focal laser ablation are considered promising but generally recommended only within clinical trials or with caution due to limited high-quality comparative data.

Clinical thresholds (selected trials & device labels)

PUL prostate volume contraindication> 100 cc

PUL age threshold>= 45 years

iTind trial IPSS inclusion>= 10

iTind trial peak flow (PFR) inclusion<= 12 mL/s (with 125 mL voided volume)

iTind prostate volume inclusion25-75 cc

Optilume (PINNACLE) IPSS inclusion>= 13

Optilume PINNACLE Qmax inclusion5-12 mL/s

Optilume prostate volume inclusion20-80 g

Optilume exclusion PVR> 300 mL

TULSA inclusion PSA (TACT trial)<= 15 ng/mL

TULSA prostate size exclusion> 90 cc or width > 6 cm or length > 5 cm

Prior Authorization

Prior authorization likely required per InterQual references

Prior authorization is likely required when InterQual references are used to define medical necessity. Obtain preauthorization as needed and include documentation demonstrating that the patient meets the referenced InterQual CP criteria to support medical necessity for the requested procedure.

Submit InterQual criteria evidence and supporting clinical documentation with the prior authorization request.
If denied, document InterQual elements used and clinical rationale for appeal.

Documentation Required

Patient selection and counseling

Document patient selection reasoning and counseling when offering PAE or other alternative procedures: record that the patient is a poor surgical candidate or has refused surgery, and document counseling regarding comparative outcomes, including higher retreatment rates for PAE versus TURP.

Note surgical/anaesthesia risk factors or contraindications to standard surgical options.
Document discussion of expected functional outcomes, retreatment risk (e.g., reported higher retreatment rates), and potential adverse events.
Include patient preference and informed consent discussion in the record.

Prior Authorization

Consideration of investigational status

For procedures labeled investigational or with insufficient evidence (for example TPLA/FLA and temporary urethral stents for broader indications), consider requiring enrollment in a clinical trial or registry or obtain prior authorization with a documented clinical rationale explaining why the procedure is appropriate despite limited evidence.

If proceeding outside a trial, document why trial enrollment is not feasible and provide detailed justification for the selected intervention.
Include available outcome data, patient-specific factors, and planned follow-up and outcome reporting.

Documentation Required

Clinical selection documentation

Document baseline clinical measures to support appropriate patient selection: record International Prostate Symptom Score (IPSS), maximum urinary flow rate (Qmax), prostate volume, post-void residual (PVR), and prostate/urethral anatomy (including presence or absence of median lobe) consistent with device/study inclusion criteria and guideline recommendations.

Capture and include IPSS and IPSS-QoL scores.
Record objective measures: Qmax, PVR, and prostate volume (imaging).
Document anatomic findings relevant to device suitability (e.g., median lobe).

Prior Authorization

Prior authorization risk for novel procedures

Prior authorization may be required for novel or non-standard prostate procedures (for example TULSA, magnetic nanoparticle ablation, and other emerging techniques). When requesting coverage, include trial evidence, patient-specific rationale, and documentation of alternative options considered.

Provide available trial data and relevant outcome measures with the authorization request.
Document why standard therapies are unsuitable or declined by the patient.

Denial Risk

Coverage risk for procedures lacking evidence

Procedures lacking sufficient evidence of safety and efficacy may be denied absent strong supporting documentation or participation in a clinical trial. For interventions listed as unproven or not medically necessary in the policy, expect a higher likelihood of coverage denial unless compelling clinical justification or trial enrollment is documented.

Provide comprehensive clinical rationale and contemporaneous evidence when requesting coverage for unproven procedures.
Consider referral to or enrollment in approved clinical trials or registries to support access.

Documentation Required

Adverse event reporting and follow-up

Record peri-procedural and follow-up adverse events and any retreatment or subsequent prostate procedures in the medical record to support outcomes assessment and ongoing safety monitoring. Examples to document include urinary tract infection, hematuria, urinary retention, urethral stricture, erectile/ejaculatory changes, and any need for retreatment (eg, TURP after PAE).

Capture timing, severity (Clavien-Dindo or grade), treatment, and resolution status of adverse events.
Document any additional procedures or medical therapy post-intervention.

Documentation Required

State fee schedule check for specific CPT codes

Verify coverage when billing CPT codes 51721, 53865, 53866, 55881, and 55882 because these codes are explicitly listed in the policy's Applicable Codes and are marked as not on the State of Louisiana Medicaid Fee Schedule; they therefore may not be covered by the State of Louisiana Medicaid Program. Confirm plan-level and state Medicaid applicability prior to billing.

Check the member's Louisiana Medicaid fee schedule and benefit terms before performing or billing for these services.
Obtain prior authorization if required by the payer and retain documentation of coverage confirmation.