CurrentUnitedHealthcarePolicy CS334KY.11

Prostate Surgeries and Interventions (for Kentucky Only)

Clinical coverage policy for multiple prostate surgeries and minimally invasive interventions for benign prostatic hyperplasia (BPH) and prostate cancer; applies only to UnitedHealthcare members in Kentucky.

Policy Summary

PayerUnitedHealthcare

PolicyProstate Surgeries and Interventions (for Kentucky Only)

Policy CodePolicy CS334KY.11

Change TypeMultiple substantive updates (criteria revisions, code list changes, added/removed procedures)

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionDocument that InterQual criteria are met for transurethral ablation, cryoablation, and water vapor thermotherapy and include required clinical measures when requesting prior authorization.

SourceLink

POLICY UPDATE CHANGES

Removed coverage criteria for transperineal placement of biodegradable material.

Revised coverage criteria for prostatic urethral lift to allow treatment of lateral with or without median lobe hyperplasia (men >=45).

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

Clarified prostate artery embolization (PAE) is proven and medically necessary specifically 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, 55881, and 55882 to Applicable Codes.

Removed CPT code 55874 from Applicable Codes.

Updated Description of Services, Clinical Evidence, FDA, and References sections to reflect current information.

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Medical Necessity Criteria by Procedure

Transurethral ablation

Covered (proven and medically necessary) when InterQual CP: Procedures, Prostatectomy, Transurethral Ablation criteria are met; otherwise unproven and not medically necessary.

ALL of the following

InterQual CP: Procedures, Prostatectomy, Transurethral Ablation criteria met
Refer to InterQual for full clinical inclusion/exclusion and documentation

Cryoablation

Covered when used for recurrent prostate cancer diagnosed by biopsy and when InterQual CP: Procedures, Cryoablation, Prostate criteria are met; unproven and not medically necessary for initial treatment of prostate cancer and all other indications.

ANY of the following

Recurrent prostate cancer diagnosed by biopsy AND InterQual CP: Procedures, Cryoablation, Prostate criteria met
Any other indication
Considered unproven and not medically necessary

Prostatic urethral lift (PUL / UroLift)

Covered when ALL of the following FDA labeled indications and contraindications are respected:

ALL of the following

Symptoms due to urinary outflow obstruction secondary to benign prostatic hyperplasia (BPH), including lateral, with or without median lobe hyperplasia
Patient is male and age ≥ 45 years
None of the following are present (all must be absent):
- Prostate volume > 100 cc
  Prostate must be ≤ 100 cc
- A urinary tract infection

High-energy water vapor thermotherapy (Rezūm)

Covered when InterQual CP: Procedures, Prostatectomy, Transurethral Ablation criteria are met for BPH treatment; unproven and not medically necessary for malignant prostate tissue and other indications.

ANY of the following

Treatment of BPH when InterQual criteria met
Treatment of malignant prostate tissue or other indications
Unproven and not medically necessary

Transurethral water jet ablation (Aquablation)

Proven and medically necessary for resection/removal of prostate tissue for LUTS due to BPH; unproven and not medically necessary for malignant prostate tissue and other indications.

ANY of the following

Treatment of LUTS due to BPH
Treatment of malignant prostate tissue or other indications
Unproven and not medically necessary

Prostate artery embolization (PAE)

Covered when ANY of the following are met; otherwise unproven and not medically necessary.

ANY of the following

Individuals with BPH who are ineligible for other procedures due to surgical constraints (e.g., prostate size) or anesthesia risk (e.g., comorbidities)
Examples of eligibility considerations: very large prostate size, advanced comorbidities, inability to tolerate anesthesia; document rationale and prior treatments
Persistent gross hematuria originating from the prostate
Any other indication
Considered unproven and not medically necessary

Other listed procedures (Not medically necessary / Unproven)

The following are unproven and not medically necessary due to insufficient evidence of safety and/or efficacy:

ANY of the following

Transperineal focal laser ablation
Insertion of a temporary prostatic urethral stent
Transperineal laser ablation (TPLA)
Ablation of malignant prostate tissue by magnetic field induction
Transurethral drug coated balloon dilation

Key Evidence Summaries by Technology

Evidence summary — Prostate Artery Embolization (PAE)

Findings from systematic reviews, RCTs, and case series; clinical conclusions and limitations:

ALL of the following

PAE may provide similar short-term improvement in patient-reported outcomes (IPSS, QoL) compared with TURP in some trials
PAE generally shows inferior improvement in objective functional measures (Qmax, prostate volume, PVR) compared with TURP in most trials
PAE is associated with fewer overall adverse events and better preservation of sexual function (erectile/ejaculatory) in several studies
PAE shows higher retreatment rates compared with TURP (e.g., ~21% required TURP within 2 years in one RCT)

Applicable Codes and Device Clearances

CPT codes - AddedCPT

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
55881	Ablation of prostate tissue, transurethral, using thermal ultrasound, including magnetic resonance imaging guidance for, and monitoring of, tissue ablation
55882	Ablation of prostate tissue, transurethral, using thermal ultrasound, including magnetic resonance imaging 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

CPT codes - RemovedCPT

55874

CPT code removed from policy (description not provided in document)

This policy includes updates to the policy's applicable code set that become effective 07/01/2025. Providers should bill using the codes listed in the policy that are applicable to the service rendered. Notably, the policy adds CPT codes 51721, 55881, and 55882 and removes CPT code 55874 from the applicable codes effective 07/01/2025; refer to the Applicable Codes section for full code descriptions and use the code that most accurately describes the performed procedure.

What Providers Must Do

Prior Authorization

Prior authorization likely required via InterQual pathways

UnitedHealthcare follows InterQual determinations for authorization of several prostate procedures; when InterQual CP: Procedures, Prostatectomy, Transurethral Ablation (and InterQual CP: Procedures, Cryoablation, Prostate) criteria apply, prior authorization is typically processed using those InterQual pathways.

Documentation Required

Use InterQual criteria where referenced

Document in the medical record that the referenced InterQual clinical coverage criteria are met for procedures where the policy directs (for example: transurethral ablation, cryoablation, and high-energy water vapor thermotherapy).

Documentation Required

Patient selection and counseling

Clinical & Study Thresholds to Reference

Key thresholds and study windows

IPSS inclusion thresholdsStudy examples: IPSS ≥ 10 (iTind trial); IPSS ≥ 13 (Optilume PINNACLE and EVEREST studies)

Qmax (peak urinary flow) thresholdsStudy windows: ≤ 12 mL/sec (iTind trial); 5–12 mL/sec (Optilume PINNACLE); 5–15 mL/sec (EVEREST and other studies)

Prostate volume windowsTypical study windows: 25–75 cc (iTind); 20–80 g (Optilume); 30–80 g (many device studies/AUA recommendations); ≤ 90 cc (TULSA exclusion in TACT)

Post-void residual (PVR) exclusionsPVR exclusions in trials: PVR > 250–300 mL excluded (Optilume EVEREST excluded PVR > 250 mL; PINNACLE excluded PVR > 300 mL)

Age thresholdsTypical age criteria: ≥ 45–50 years (e.g., PUL indication: men ≥ 45; iTind and Optilume trials enrolled ages ≥ 50 in many studies)

PAE retreatment rate

Defined Terms

Definitions

InterQualA proprietary clinical decision support tool referenced for specific medical necessity criteria for several procedures.

LUTSLower urinary tract symptoms.

BPHBenign prostatic hyperplasia.

IPSSInternational Prostate Symptom Score — patient-reported measure of LUTS severity.

QmaxMaximum urinary flow rate measured in mL/s (peak urinary flow rate).

PVRPost-void residual urine volume.

Clinical and Administrative Background

This Kentucky-specific clinical policy addresses surgical and minimally invasive interventions for benign prostatic hyperplasia (BPH) and select indications in prostate cancer. Covered (proven and medically necessary) therapies include transurethral ablation when InterQual CP: Procedures, Prostatectomy, Transurethral Ablation criteria are met, cryoablation for biopsy-proven recurrent prostate cancer when InterQual criteria are met, prostatic urethral lift (UroLift) when performed within FDA-labeled indications, high-energy water vapor thermotherapy (Rezūm) when InterQual criteria are met for BPH, transurethral water jet ablation (Aquabeam) for LUTS due to BPH, and prostate artery embolization (PAE) for individuals with BPH who are ineligible for other procedures due to surgical constraints or anesthesia risk or for persistent gross prostatic hematuria. (See policy sections for specific InterQual references and device labeling.)

The policy also categorizes several procedures as unproven and not medically necessary due to insufficient evidence of safety and/or efficacy. These include transperineal focal laser ablation and transperineal laser ablation (TPLA) for many indications, insertion of temporary prostatic urethral stents, ablation of malignant prostate tissue by magnetic field induction (nanoparticle hyperthermia), transurethral drug-coated balloon dilation, and transurethral thermal ultrasound ablation (TULSA) for prostate cancer outside of research settings.

Evidence summaries in the policy distinguish stronger (proven) indications from those with limited or low-quality evidence. For example, randomized and comparative data support specific BPH treatments (Aquablation, UroLift, Rezūm) with defined inclusion thresholds and InterQual-referenced medical necessity pathways, while focal oncologic and several novel technologies (e.g., magnetic nanoparticle hyperthermia, TULSA, many focal ablation techniques) have limited comparative or long-term oncologic data and are recommended only in clinical trials or for carefully selected patients. The policy references FDA device clearances and guideline statements and emphasizes patient selection, documentation of InterQual criteria where required, and counseling about limited long-term evidence and retreatment risk (e.g., higher retreatment rates reported with PAE in some trials).

Policy Changes and Effective Dates

2025-07-01effective_date / code updates / coverage rationale changesLatest

Policy updated effective July 1, 2025: removed coverage criteria for transperineal placement of biodegradable material; revised prostatic urethral lift criteria to allow lateral with or without median lobe hyperplasia; clarified transurethral water jet ablation language to specify it is unproven for malignant prostate tissue and other non-proven indications; clarified PAE indications to specify BPH patients ineligible for other procedures due to surgical constraints or anesthesia risk; added TULSA to unproven procedures; added CPT codes 51721, 55881, and 55882; removed CPT code 55874; supporting sections refreshed and prior version CS334KY.10 archived.

2025-07-01applicable_codes_effective_date

Applicable codes list updated effective July 1, 2025 — CPT codes 51721, 55881, and 55882 were added and CPT code 55874 was removed.

Policy Summary

PayerUnitedHealthcare

PolicyProstate Surgeries and Interventions (for Kentucky Only)

Policy CodePolicy CS334KY.11

Change TypeMultiple substantive updates (criteria revisions, code list changes, added/removed procedures)

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionDocument that InterQual criteria are met for transurethral ablation, cryoablation, and water vapor thermotherapy and include required clinical measures when requesting prior authorization.

SourceLink

On This Page

Evidence summary — Transperineal Laser Ablation (TPLA / FLA)

Findings from RCTs, systematic reviews, and consensus statements; clinical conclusions and limitations:

ALL of the following

TPLA/FLA has insufficient high-quality evidence for oncologic effectiveness in prostate cancer and long-term outcomes are lacking
Two RCTs showed inferiority of TPLA compared to TURP on many efficacy outcomes but superiority in preserving ejaculatory function
Systematic reviews and expert consensus view FLA/TPLA as promising but recommend restriction to clinical trials or carefully selected patients
Limitations include small sample sizes, short follow-up, heterogeneous patient selection and outcome definitions

Evidence summary — Temporary urethral stents (iTind)

Findings from RCTs, MAICs, prospective cohorts and technology assessments:

ALL of the following

iTind showed variable efficacy vs sham and noninferior/competitive outcomes vs other minimally invasive treatments in indirect comparisons
RCT vs sham: improvement in IPSS favored iTind for proportion achieving ≥3-point improvement, but primary endpoint differences often not statistically robust
MAIC comparing iTind to UroLift reported similar efficacy and differing AE profiles; limitations due to indirect comparisons
Longer-term single-arm studies report durable symptom improvement up to 3–4 years in subsets but with substantial loss to follow-up
Evidence quality limited by risk of bias, small samples, indirect comparisons, and exclusion of larger prostates/median lobe patients

Transurethral drug-coated balloon (Optilume BPH Catheter System)

Evidence from sham-controlled RCTs and single-arm studies shows symptom and flow improvement up to 4 years but lacking direct comparisons to established BPH therapies:

ALL of the following

PINNACLE RCT inclusion criteria example: age 50–80, IPSS ≥ 13, Qmax 5–12 mL/s, prostate volume 20–80 g, prostatic urethral length 32–55 mm
Randomized 2:1 to Optilume vs sham; sham could cross over at 3 months
Outcomes: clinically meaningful IPSS reduction (e.g., mean -11.5 at 1 year), improved Qmax and reduced PVR; sexual function preserved in trials
Adverse events mainly hematuria, UTI; some postprocedural complications requiring intervention reported
Single-arm follow-up and some loss to follow-up limit strength of evidence2–4 years follow-up

Transurethral thermal ultrasound ablation (TULSA) for prostate cancer

Evidence limited to single-arm prospective trials; insufficient comparative long-term oncologic outcomes:

ALL of the following

TACT pivotal trial (Klotz et al. 2021): MRI-guided whole gland TULSA in favorable to intermediate-risk prostate cancer (age 45–80; GG1–2; PSA ≤ 15 ng/mL; prostate ≤ 90 cc; other MRI/implant exclusions)
Reported inclusion: age 45–80; GG1–2; PSA ≤ 15; prostate ≤ 90 cc
Reported PSA reductions, prostate volume decrease, and no evidence of cancer in a subset at 12 months; some Grade 3 AEs resolved by 12 months
Functional outcomes (erectile/urinary) often decline early and partially recover by 12 months
Limitations: small size, short follow-up, lack of comparators

Transurethral drug-coated balloon / other novel BPH technologies - General evidence statement

Overall evidence considerations across devices:

ANY of the following

Many novel therapies show symptomatic and objective urinary improvements in single-arm or sham-controlled trials
Limitations common to studies: small sample sizes, loss to follow-up, short-term follow-up, few head-to-head comparisons with established therapies (TURP, PVP, HoLEP, etc.)
Adverse events commonly reported: hematuria, urinary retention, UTI, dysuria, ejaculatory changes; most resolved within months

Ablation of malignant prostate tissue by magnetic field induction (nanoparticle hyperthermia)

Very limited evidence (phase I) — insufficient to determine safety and efficacy:

ALL of the following

Phase I trial (Johannsen et al.): 10 patients with locally recurrent prostate cancer after prior curative treatment; primary endpoints feasibility and toxicity
Feasible but nanoparticle distribution inconsistent; some Grade 3 urinary toxicities; localized discomfort with higher field strengths
Conclusion: further research required due to inconsistent intratumoral distribution and heating outside target volumes

Prostate Surgeries and Interventions (for Kentucky Only)

Medical Necessity Criteria by Procedure

Key Evidence Summaries by Technology

Applicable Codes and Device Clearances

What Providers Must Do

Clinical & Study Thresholds to Reference

Defined Terms

Clinical and Administrative Background

Other Policies to Review

Policy Changes and Effective Dates