RetiredUnitedHealthcarePolicy CS334LA.F

Prostate Surgeries Interventions La Cs

State-specific UnitedHealthcare medical policy for prostate surgeries and interventions in Louisiana describing medical necessity vs not medically necessary determinations for multiple prostate procedures (transurethral ablation, cryoablation, prostatic urethral lift, water vapor thermotherapy, transurethral water jet ablation, prostate artery embolization, and other procedures), with references to InterQual criteria and applicable CPT/HCPCS codes. This is Part 1 of 4 and includes clinical statements, evidence summaries, code lists, and procedural descriptions.

Policy Summary

PayerUnitedHealthcare

PolicyProstate Surgeries Interventions La Cs

Policy CodePolicy CS334LA.F

Change TypeRetirement and multiple coverage/coding revisions

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionProviders should refer to and document InterQual clinical criteria and FDA labeled indications/contraindications when requesting coverage and verify state fee-schedule coverage for added CPT codes prior to billing.

SourceLink

POLICY UPDATE CHANGES

Policy retired effective April 1, 2026

Revised coverage criteria for prostatic urethral lift to 'including lateral, with or without median lobe hyperplasia' wording.

Clarified transurethral water jet ablation is unproven and not medically necessary for malignant prostate tissue and other indications not listed as proven due to insufficient evidence.

Revised PAE wording to specify it is 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 list of unproven and not medically necessary procedures.

Added CPT codes 51721, 53865, 53866, 55881, and 55882 to Applicable Codes.

Removed CPT code 55874 from Applicable Codes.

Removed coverage criteria for transperineal placement of biodegradable material.

Retired policy; Louisiana plan membership disenrolled on Apr. 1, 2026.

Updated description of services, clinical evidence, FDA, and references sections to reflect current information.

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Procedures addressed

Low-ModerateEvidence certainty

21%PAE retreatment reported

1Policy retirement events

Coverage Summary

This is the State-specific UnitedHealthcare medical policy for prostate surgeries and interventions in Louisiana. It describes medical necessity versus not medically necessary determinations for multiple prostate procedures (transurethral ablation, cryoablation, prostatic urethral lift, water vapor thermotherapy, transurethral water jet ablation, prostate artery embolization, and other procedures) and references InterQual criteria and applicable CPT/HCPCS codes. Effective date range: August 1, 2025 - March 31, 2026.

Note: Policy retired effective April 1, 2026; Louisiana plan membership was disenrolled on that date. Providers should confirm current coverage requirements and authorization processes for affected members.

Key thresholds & quick facts

Procedures addressedMultiple procedures

Applies toState-specific (Louisiana only)

Overall evidence certaintyLow-Moderate

PAE retreatment (Abt et al.)21% conversion to TURP within 2 years

Policy retirement eventsRetired Apr 1, 2026 (Louisiana plan membership disenrolled)

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

IPSS inclusion thresholds (examples)Often ≥10 or ≥12 (varies by study)

Qmax inclusion thresholds (examples)Often ≤12–15 mL/s (varies by study)

Prostate volume limits (examples)Often <75–100 mL depending on device/study; some studies include larger prostates

Medical-Necessity Criteria

Evidence Summaries by Technology

High-level evidence summary: the policy references systematic reviews, randomized controlled trials, health technology assessments (Hayes, ECRI), and InterQual criteria to define when procedures are considered proven/medically necessary versus unproven/not medically necessary.

Major themes about limitations noted across the evidence: many studies are small or single-arm, follow-up durations are often short, and there is substantial heterogeneity in patient selection, interventions, and outcomes—resulting in low to moderate certainty for many outcomes and uncertainty about long-term safety and durability.

Selected evidence highlights

PAE — randomized trial (Abt et al.)PAE had inferior functional outcomes to TURP and 21% of PAE patients required TURP within 2 years

Aquablation (TURP RCT, Gilling et al.)Multicenter double-blind RCT vs TURP showed similar or slightly favorable IPSS outcomes up to 5 years; lower 5‑yr retreatment vs TURP in some analyses

iTind — 3‑year single-arm outcomes (Amapore et al.)Durable improvements in IPSS, QoL, Qmax, PVR at 3 years; median lobe presence predicts failure

Optilume — PINNACLE RCT

Coding (Applicable Codes & Devices)

Referenced/procedural codes (for reference only)CPT

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 all intraprocedural, transperineal needle/catheter placement for nanoparticle installation and intraprocedural temperature monitoring, thermal dosimetry, bladder irrigation, and magnetic field nanoparticle activation
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, intraprocedural road mapping, and imaging guidance necessary to complete the intervention: for tumors, organ ischemia, or infarction (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

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FDA-cleared / approved devices mentionedmixed

UroLift (Teleflex) K193269	FDA 510(k) clearance for UroLift System for treatment of symptoms due to outflow obstruction secondary to BPH (includes lateral and median lobe) in men 45 or older (cleared Dec 20, 2013)
Rezūm (Boston Scientific) K191505	FDA 510(k) clearance for Rezūm Water Vapor Therapy system for treatment of symptoms of BPH including median lobe (cleared Aug 2, 2019)
Spanner Temporary Prostatic Stent PMA P060010	Spanner Temporary Prostatic Stent approved via PMA (Dec 14, 2006)
iTind 510(k) K210138	iTind cleared under 510(k) (June 2021)
Aquabeam 510(k) K202961	Aquabeam Robotic System 510(k) approval (Mar 3, 2021)
Optilume PMA P220029A	Optilume Urethral Drug Coated Balloon PMA (June 30, 2023) for obstructive urinary symptoms associated with BPH in men ≥ 50 years
ECHOLASER X4 510(k) (2018)	ECHOLASER X4 system 510(k) for cutting, vaporization, ablation/coagulation of soft tissue (Sep 2018)
High intensity ultrasound systems product code PLP	High intensity ultrasound ablation systems cleared under 510(k)

Added CPT codes (Applicable Codes)CPT

51721
53865
53866
55881
55882

Removed CPT codesCPTNot Covered

55874

Billing note: CPT codes 51721, 53865, 53866, 55881, and 55882 were added to the policy's Applicable Codes list but are marked as not on the State of Louisiana Medicaid Fee Schedule and therefore may not be covered by Louisiana Medicaid.

Providers must verify state fee-schedule coverage prior to billing and confirm coverage/authorization requirements for State of Louisiana Medicaid members.

Provider Actions & Prior Authorization

Documentation Required

Reference InterQual criteria for medical necessity

Providers must refer to and document criteria per InterQual CP (Procedures: Prostatectomy, Transurethral Ablation; Cryoablation, Prostate) when requesting coverage for transurethral ablation or cryoablation.

Documentation Required

Follow FDA labeled indications/contraindications for PUL

For Prostatic Urethral Lift (PUL), document compliance with FDA labeled indications, contraindications, warnings, and precautions prior to scheduling or billing.

Patient age (must be ≥ 45 years)
Primary diagnosis: symptomatic urinary outflow obstruction secondary to BPH
Prostate volume (document measured volume; PUL not for prostate volume > 100 cc)
Absence of listed contraindications: active urinary tract infection, urethral conditions preventing delivery system insertion, urinary incontinence due to incompetent sphincter, current gross hematuria

Definitions

PUL — Prostatic urethral lift: placement of permanent implants to hold open prostate lobes; indicated per FDA labeling for treating urinary outflow obstruction due to BPH.

PAE — Prostate artery embolization: injection of microspheres into prostatic arteries to occlude vessels and reduce prostate volume.

BPH — Benign prostatic hyperplasia: non-malignant enlargement of the prostate that can cause lower urinary tract symptoms.

IPSS — International Prostate Symptom Score: patient-reported symptom measure for lower urinary tract symptoms.

Qmax — Maximum urine flow rate (mL/s).

PVR — Post-void residual urine volume.

TPLA/FLA — Transperineal focal/laser ablation: minimally invasive thermal ablation of prostate tissue (used for focal treatment of prostate cancer and for BPH in some studies).

Revision History

April 1, 2026retiredLatest

Policy retired effective April 1, 2026; Louisiana plan membership disenrolled on Apr. 1, 2026.

August 1, 2025 - March 31, 2026effective_date_range

Policy effective date range August 1, 2025 through March 31, 2026 (header detail).

08/01/2025added_codes

Policy Summary

PayerUnitedHealthcare

PolicyProstate Surgeries Interventions La Cs

Policy CodePolicy CS334LA.F

Change TypeRetirement and multiple coverage/coding revisions

Effective DateAug 1, 2025

Next Review DateN/A

SourceLink

On This Page

Mean IPSS reduction ~11.5 at 1 year; 2‑yr responder rate 67% (≥30% improvement without retreatment); Qmax improved substantially

TULSA pivotal (TACT)In 115 men PSA reduction >75% in 110; median prostate volume decrease 91%; 72 had no evidence of cancer at 12 months; some grade 3 AEs resolved by 12 months

iTind RCT (Chughtai 2020)iTind vs sham: IPSS change −9.0 vs −6.6 at 3 months (p=0.063); 78.6% vs 60% achieved ≥3‑point IPSS reduction (p=0.029); AEs 38.1% vs 17.5%

PAE evidence synthesesSystematic reviews/Cochrane: similar symptom/QoL vs TURP but increased retreatment; certainty low to very low (retreatment moderate certainty)

Documentation Required

Study selection, patient selection, and counseling on retreatment risk

Study selection, limitations, and patient selection considerations — document rationale and counseling.

Study selection & limitations: Document which clinical trials/guidelines informed the treatment decision and note limitations (sample size, duration of follow-up, applicability to individual patient anatomy or comorbidities).
Patient selection considerations: Document symptom severity, prior medical therapy tried and failed, prostate anatomy (including presence/size of median lobe), prostate volume measurement, and anesthesia/surgical risk that influenced selecting the procedure.
Counseling on retreatment risk: Document that patient was counseled on the potential need for retreatment or secondary procedures (include quoted retreatment rates from referenced studies if used in counseling) and that patient understands alternative therapies and expected outcomes.

Documentation Required

Clinical criteria to document

Clinical criteria to document from trials/guidelines when requesting coverage — include objective measures and prior conservative therapy.

Baseline symptom scores (e.g., IPSS) and voiding/quality-of-life measures
Objective urinary measures: post-void residual (PVR) volume, peak urinary flow rate (Qmax)
Prostate size/volume (imaging or ultrasound measurement)
History of prior therapies attempted (medication classes, duration, response) and reason for discontinuation or failure
For cryoablation (recurrent prostate cancer): biopsy-confirmed recurrence, prior definitive therapy details, and any imaging or PSA trends supporting recurrence

Documentation Required

Prior authorization implication

Prior authorization implications: confirm requirements and document clinical rationale per InterQual and plan rules before submitting request.

Obtain and attach InterQual-based clinical documentation to prior authorization requests when applicable
Include objective test results and prior therapy history to support medical necessity

Billing Rule

State fee schedule implications for added CPT codes

State fee schedule implications for added CPT codes — verify state-specific coverage prior to billing.

Affected codes: 51721, 53865, 53866, 55881, 55882
Action: verify state fee-schedule coverage prior to billing

Prior Authorization

Policy retirement for Louisiana membership

Policy retirement for Louisiana membership — retirement effective April 1, 2026. Providers must confirm current coverage and authorization processes for affected members given the policy retirement date.

Retirement date: April 1, 2026
Action: Confirm whether alternative or successor coverage policies, prior authorization pathways, or state-mandated rules now apply for Louisiana members prior to performing or billing services

Added CPT codes 51721, 53865, 53866, 55881, and 55882 to Applicable Codes (notation: these codes are not on the State of Louisiana Medicaid Fee Schedule).

08/01/2025removed_codes

Removed CPT code 55874 from Applicable Codes.

08/01/2025revised

Revised Prostatic Urethral Lift (PUL) coverage wording to specify treatment for LUTS due to BPH 'including lateral, with or without median lobe hyperplasia' per FDA labeled indications and contraindications.

08/01/2025revised

Clarified transurethral water jet ablation (Aquablation) is proven for LUTS due to BPH and specified it is unproven and not medically necessary for treatment of malignant prostate tissue and all other indications not listed as proven due to insufficient evidence of safety and/or efficacy.

08/01/2025revised

Revised Prostate Artery Embolization (PAE) wording to specify PAE is proven and medically necessary for individuals with BPH who are ineligible for other procedures due to surgical constraints (e.g., prostate size) or anesthesia risk (e.g., comorbidities), and for persistent gross hematuria originating from the prostate.

08/01/2025added

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

08/01/2025revised

Removed coverage criteria for transperineal placement of biodegradable material from the policy.

08/01/2025archived

Archived previous policy version CS334LA.E and updated Description of Services, Clinical Evidence, FDA, and References sections to reflect current information.