Use of prostatic urethral lift in individuals with moderate-to-severe lower urinary tract obstruction due to benign prostatic hyperplasia may be considered medically necessary when all of the following criteria are met:
The individual has persistent or progressive lower urinary tract symptoms despite medical therapy (α1-adrenergic antagonists maximally titrated, 5α-reductase inhibitors, or combination medication therapy maximally titrated) over a trial period of no less than 6 months, or is unable to tolerate medical therapy; AND,
Prostate gland volume is ≤80 mL; AND,
Prostate anatomy demonstrates normal bladder neck without an obstructive or protruding median lobe; AND,
Individual does not have urinary retention related to conditions other than benign prostatic hyperplasia, urinary tract infection, or recent prostatitis (within past year); AND,
Individual has had appropriate testing to exclude diagnosis of prostate cancer; AND,
Individual does not have a known allergy to nickel, titanium or stainless steel.
Use of prostatic urethral lift in other situations, including repeat procedures, is considered investigational
