Local Coverage Determination (LCD)

Laser Ablation of the Prostate

L34090

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Contractor Information

LCD Information

Document Information

LCD ID
L34090
LCD Title
Laser Ablation of the Prostate
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 03/24/2022
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

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Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2021 American Dental Association. All rights reserved.

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Issue

Issue Description

This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations and/or Medical Necessity.

CMS National Coverage Policy

Language quoted from Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act (SSA):

Section 1862(a)(1)(A) excludes expenses incurred for items or services, which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

National Coverage Determination 140.5 Laser Procedures

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Abstract:

Benign prostatic hyperplasia is an enlargement of the prostate gland that frequently occurs in men as they age. Current treatments include watchful waiting, medications i.e., alpha-blockers, and surgery. The gold standard for treating this condition is a transurethral resection of the prostate (TURP). Some patients may not be healthy enough to undergo this procedure and choose a less invasive procedure to treat this condition. This local coverage determination (LCD) addresses laser therapy of the prostate.

Laser prostatectomy, or visual laser ablation of the prostate (VLAP) is an alternative technique to the conventional surgical intervention of transurethral resection of the prostate (TURP) in treating bladder outlet obstruction caused by benign prostate hypertrophy (BPH).

Laser ablation of the prostate involves delivery of laser energy to the prostate in one of five main variations. These are: the transurethral ultrasound-guided laser-induced prostatectomy (TULIP), the free-fiber visually guided laser ablation of the prostate (VLAP), visually guided contact laser ablation of the prostate (CLAP), ultrasound guided interstitial laser coagulation of the prostate (ILCP), and the Holmium: YAG Laser (holmium laser ablation of the prostate -HoLAP, and holmium enucleation of the prostate - HoLEP).

Laser enucleation of the prostate using a high power laser source is performed on a small subset of patients requiring prostate surgery due to the enlarged size of the prostate. A laser fiber is used to undermine and dissect away large pieces of prostate tissue that migrate into the bladder and are subsequently extracted at the end of the procedure.

Indications:

Laser prostatectomy is indicated as a treatment modality for patients with bladder neck obstruction secondary to benign prostatic hyperplasia (BPH). Laser surgery provides some advantages over traditional TURP in that the hospital stay is decreased, patients can resume normal activities quicker and morbidity is reduced.

These procedures will be covered for the following indications:

  1. Duration of BPH 3 months or longer;
  2. American Urology Association (AUA) symptom score greater than 9 Urodynamics and Post-void Residual Volume examinations should be used as appropriate, e.g., patients with suspected neurologic disease or those who have failed prostate surgery.

    Limitations:

    A relative contraindication for these procedures is an active urinary infection.

    The use of these devices must be prescribed and administered under the personal supervision of a qualified and trained physician, after appropriate urological evaluation of the patient. The treating physician must be present at all times during the treatment.

    Other Comments:

    For claims submitted to the Part A MAC: This coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS Administrators, LLC to process their claims.

    Bill type codes only apply to providers who bill these services to the Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

    Limitation of liability and refund requirements apply when denials are based on medical necessity. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be considered medically necessary by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.

    For dates of service on or after April 1, 2010, bill type 77X should be used to report FQHC services.

    For outpatient settings other than CORFs, references to "physicians" throughout this policy include non-physicians, such as nurse practitioners, clinical nurse specialists and physician assistants. Such non-physician practitioners, with certain exceptions, may certify, order and establish the plan of care as authorized by State law. (See Sections 1861[s][2] and 1862[a][14] of Title XVIII of the Social Security Act; 42 CFR, Sections 410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000.)
Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

General Information

Associated Information

The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

The medical record/progress notes must document the duration of BPH, AUA symptoms index, and the urodynamics studies and/or post-void residual volume results if performed.

Each claim must be submitted with ICD-10-CM codes that reflect the condition of the patient, and indicate the reason(s) for which the service was performed. Claims submitted without ICD-10-CM codes will be returned.

Documentation must be available to Medicare upon request.

Not applicable

Not applicable

Sources of Information

This bibliography presents those sources that were obtained during the development of this policy. CGS Administrators, LLC is not responsible for the continuing viability of Web site addresses listed below.

Benign Prostatic Hyperplasia (BPH)/Enlarged Prostate – Thermal Treatments, June 10, 1998. urologychannel® Web site. http://www.urologychannel.com/prostate/bph/treatment_therm.shtml. Accessed October 13, 2009.

Keoghane SR, Lawrence KC, Gray AM, et al. A double-blind randomized controlled trial and economic evaluation of transurethral resection vs. contact laser vaporization for benign prostatic enlargement: a 3-year follow-up. BJU Int. 2000;85(1):74-78.

Tanagho EA, McAninch JW. Neoplasms of the rrostate gland. Smith's General Urology. 17th ed. McGraw-Hill; 2008.
http://www.accessmedicine.com/resourceTOC.aspx?resourceID=21. Accessed October 13, 2009.

Witjes WP, Robertson A, Rosier PF, Neal DE, Debruyne FM, de la Rosette JJ. Urodynamic and clinical effects on noninvasive and minimally invasive treatments in elderly men with lower urinary tract symptoms stratified according to the grade of obstruction. Urology. 1997;50(1):55-61.

Bibliography

N/A

Revision History Information

Revision History DateRevision History NumberRevision History ExplanationReasons for Change
03/24/2022 R11

R11

Revision Effective: 03/24/2022

Revision Explanation: Annual Review, no changes made.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Other (Annual Review)
04/01/2021 R10

R10

Revision Effective: 04/01/2021

Revision Explanation: Annual Review, no changes made.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Other (Annual Review)
09/19/2019 R9

R9

Revision Effective: N/A

Revision Explanation: Annual Review, no changes made.

3-25-2020:At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Other (Annual Review)
09/19/2019 R8

R8

Revision Effective: 09/19/2019 Revision Explanation: Converted policy into new policy template that no longer includes coding section based on CR 10901. For Approval, no changes.

09/13/2019:At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Revisions Due To Code Removal
09/19/2019 R7

R7

Revision Effective: 09/19/2019 Revision Explanation: Converted policy into new policy template that no longer includes coding section based on CR 10901.

09/12/2019:At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Revisions Due To Code Removal
04/11/2019 R6

R6
Revision Effective: 04/11/2019
Revision Explanation: Removed all billing and coding details from policy into related Billing and Coding article. Coding information was removed based on CR10901. Also, retired A52390-Laser Ablation of the Prostate-Supplemental Instructions Article.

04/05/2019:At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Other (Removed billing and coding based on CR10901)
10/01/2015 R5

R4 Revision Effective: N/A

Revision Explanation: Annual review no changes made at this time.

03-13-2019: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Other (Annual Review)
10/01/2015 R4

R3
Revision Effective: N/A
Revision Explanation: Annual review no changes made at this time.

03/28/2018: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Other (Annual Review)
10/01/2015 R3 R3
Revision Effective: N/A
Revision Explanation: Annual review no changes made at this time.
  • Other (Annual review)
10/01/2015 R2 R2
Revision Effective: N/A
Revision Explanation: Annual review no changes made at this time.
  • Other (Annual review)
10/01/2015 R1 R1
Revision Effective: 10/01/2015
Revision Explanation: Accepted revenue code description changes.
  • Other (revenue code description)

Associated Documents

Attachments
N/A
Related Local Coverage Documents
Articles
A56467 - Billing and Coding: Laser Ablation of the Prostate
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
03/18/2022 03/24/2022 - N/A Currently in Effect You are here
03/23/2021 04/01/2021 - 03/23/2022 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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