When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
52441, 52442, 52450, 52601, 52630, 53850, 55821, 55831
THE FOLLOWING CODE IS USED TO REPRESENT HOLMIUM LASER ABLATION OF THE PROSTATE (HoLAP), PHOTOSELECTIVE VAPORIZATION (PVP), and TRANSURETHRAL ELECTROVAPORIZATION OF THE PROSTATE (TUVP):
THE FOLLOWING CODE IS USED TO REPRESENT HOLMIUM LASER ENUCLEATION OF THE PROSTATE (HoLEP) and HOLMIUM LASER RESECTION OF THE PROSTATE (HoLRP):
NOT MEDICALLY NECESSARY
THE FOLLOWING CODE IS USED TO REPRESENT VISUAL LASER ABLATION OF THE PROSTATE (VLAP) AND INTERSTITIAL LASER COAGULATION (ILC):
THE FOLLOWING CODES ARE USED TO REPRESENT TRANSURETHRAL ULTRASOUND-GUIDED LASER-INDUCED PROSTATECTOMY (TULIP):
THE FOLLOWING CODES ARE USED TO REPRESENT WATER-INDUCED THERMOTHERAPY (WIT) OF THE PROSTATE:
0421T, 37243, 53854
THE FOLLOWING CODE IS USED TO REPRESENT TRANSURETHRAL BALLOON DILATION OF THE PROSTATE:
THE FOLLOWING CODE IS USED TO REPRESENT TRANSURETHRAL ETHANOL ABLATION OF THE PROSTATE (TEAP):
THE FOLLOWING CODE IS USED TO REPRESENT HIGH-INTENSITY FOCUSED ULTRASOUND (HIFU) OF THE PROSTATE:
N40.1 Benign prostatic hyperplasia with lower urinary tract symptoms
N40.3 Nodular prostate with lower urinary tract symptoms
Policy: 11.11.03d:Cryosurgical Ablation of the Prostate Gland