Local Coverage Determination (LCD)

Laser Ablation of the Prostate

L34090

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L34090
Original ICD-9 LCD ID
Not Applicable
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 04/04/2024
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A

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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.

Issue - Explanation of Change Between Proposed LCD and Final LCD

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.


Summary of Evidence

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Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
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Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
View Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description

Please accept the License to see the codes.

N/A

Revenue Codes

Code Description

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N/A

CPT/HCPCS Codes

Please accept the License to see the codes.

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

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Additional ICD-10 Information

General Information

Associated Information
N/A
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 Date Revision History Number Revision History Explanation Reasons for Change
04/04/2024 R14

R14

Revision Effective: 04/04/2024

Revision Explanation: Update to R13, Annual Review, removed billing and coding related details to the associated billing and coding article.

03/29/2024 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)
04/04/2024 R13

R13

Revision Effective: 04/04/2024

Revision Explanation: Annual Review, no changes made.

03/29/2024 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)
03/23/2023 R12

R12

Revision Effective: 03/23/2023

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)
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)
N/A

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
03/29/2024 04/04/2024 - N/A Currently in Effect You are here
03/15/2023 03/23/2023 - 04/03/2024 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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