Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
Billing and coding: diagnoses and procedure codes
Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A58209 (Billing and Coding: Transurethral Waterjet Ablation of the Prostate) carries the diagnosis and procedure lists the contractor loads as the claims edit. CPT codes are shown as bare numbers because the descriptors are licensed by the AMA; HCPCS Level II descriptors are public and shown.
A58209: Billing and Coding: Transurethral Waterjet Ablation of the Prostate (Billing and Coding, effective 2026-01-01)
- Covered ICD-10-CM codes
- 1
- 1 group
- Non-covered ICD-10-CM codes
- 0
- Procedure codes listed
- 2
- Full article
- cms.gov record
| ICD-10-CM | Description (FY2027) |
|---|---|
| N40.1 | — |
Procedure codes: 52597, C2596 (Probe, Image-Guided, Robotic, Waterjet Ablation).
Coverage indications, limitations and medical necessity
Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.
History/Background and/or General Information
Benign prostatic hyperplasia (BPH) is a histological diagnosis characterized by an increased number of epithelial and stromal cells in the prostate. It is common in men over the age of 40, and the incidence increases with age. In the United States, 8 million men older than 50 years old suffer from BPH. In many cases BPH is asymptomatic, however, symptoms may occur with prostate enlargement and compression of the urethra leading to bothersome lower urinary tract symptoms (LUTS), including voiding symptoms such as hesitancy, weak stream, straining, prolonged voiding, and storage symptoms (frequency, urgency, and nocturia). LUTS/BPH can have a significant impact on the quality of life and can cause serious complications such as infections, bleeding, calculus formation, urinary retention and decline of renal function when untreated. 1 First line treatment generally consists of treatment with medications such as alpha blockers, PDE5 Inhibitors, or finasteride/dutasteride. If treatment with medications is not successful, surgical options may then be considered. Transurethral resection of the prostate (TURP) and open simple prostatectomy (OSP) are the standard surgical treatments for LUTS/BPH and are highly effective and provide improved outcomes in urinary functions. However, neither TURP nor OSP are without considerable perioperative complication and morbidity. 2 Recently, new minimally invasive surgeries have emerged as alternatives for the resection of the prostate to manage LUTS in men with BPH. One such surgery is transurethral waterjet ablation which is minimally invasive; water based surgical therapy that combines image
guidance and robotics to remove prostatic tissue. 3 The system works by pumping high pressure saline (500 to 8000 pounds per square [PSI]) through a probe nozzle to cut and dissect tissue at predetermined system parameters. 3
Covered Indications
Treatment for LUTS/BPH will be considered reasonable and necessary ONCE per lifetime in patients with:
• All of the following indications:
• Prostate volume of 30-150ml 4,5
• Persistent moderate to severe symptoms despite maximal medical management including ALL of the following:
• International Prostate Symptom Score (IPSS) ≥12 4
• Maximum urinary flow rate (Qmax) of ≤15 mL/s 4,5
• Failure, contraindication or intolerance to at least 3 months of conventional medical therapy for LUTS/BPH (e.g., alpha blocker, PDE5 Inhibitor, finasteride/dutasteride)
• Only treatment using an FDA approved/cleared device will be considered reasonable and necessary.
Limitations
Transurethral waterjet ablation of the prostate is not considered reasonable and necessary for patients with the following:
• Body mass index ≥ 42kg/m2 6
• Known or suspected prostate cancer (based on NCCN Prostate Cancer Early Detection guidelines 7 ) or a prostate specific antigen (PSA) > 10 ng/mL unless the patient has had a negative prostate biopsy within the last 6 months.
• Bladder cancer, neurogenic bladder, bladder calculus or clinically significant bladder diverticulum 6
• Active urinary tract or systemic infection 6
• Treatment for chronic prostatitis 6
• Diagnosis of urethral stricture, meatal stenosis, or bladder neck contracture 6
• Damaged external urinary sphincter 6
• Known allergy to device materials 8
• Inability to safely stop anticoagulants or antiplatelet agents preoperatively. 8
Notice: Services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in this LCD.
Summary of evidence (opening)
Year 1, Year 2 and Year 3 Outcomes
Initial clinical experience was reported in 2016, and the technology obtained FDA clearance in 2017 after the publication of the WATER trial, a PHASE III multicenter international, double blind, randomized, non-inferiority study with 181 subjects comparing Aquablation ® (116/181) to TURP (65/181). 9 Men 45-80 years old with prostate size 30-80 cc (by TRUS), moderate-severe LUTS (International Prostate Symptom Score (IPSS) ≥ 12), and maximum urinary flow rate (Qmax) ® and TURP, respectively (noninferiority p ® group than in the TURP group (26% vs 42%, p = 0.0149). At 2 years, IPSS score improvement was sustained (14.7 in Aquablation ® and 14.9 in TURP (p=0.834, 95% CI for difference -2.1 to 2.6)), and Qmax improvement was large in both groups (11.2 and 8.6 cc/s for Aquablation ® and TURP, respectively (p = 0.1880, 95% CI for difference -1.3 to 6.4). 10 Two-year reduction in post-void residual (PVR) was 57 and 70 cc for Aquablation ® and TURP, respectively (p = 0.3895). Prostate specific antigen (PSA) decreased significantly in both groups by 1 point (p ® and TURP groups, respectively. Among the subset of sexually active men without the condition at baseline, anejaculation was less common after Aquablation ® (10% vs. 36%, p=0.0003). When post-Aquablation ® cautery was avoided rates of anejaculation were lower (7% vs. 16%, p=0.1774), and this resulted in the reduced grade 1 persistent events found in the Aquablation ® group. The authors hypothesize that Aquablation ® avoids damage to tissues involved in ejaculation though precise, image-based targeting, and robotic execution. Limitations of the study include the risk of performance bias as surgeons were not blinded, and unknown generalizability to a broader population. Three-year results were essentially unchanged. 4
Gilling PJ et al. (2022) published the 5-year follow-up data for the WATER study. 20 Five-year follow-up revealed IPSS scores improved by 15.1 points in the Aquablation ® group and 13.2 points in TURP (p = 0.2764). IPSS reduction was 3.5 points greater across all follow-up visits in the Aquablation ® group compared to the TURP group (p = 0.0123) for men with larger prostates (≥50mL). Peak urinary flow rates for Aquablation ® and TURP improved when compared to baseline (125% and 89% respectively). 12.3% of patients treated with TURP required a subsequent intervention compared to 6% of patients treated with Aquablation ® , up to 5 years secondary to recurrent LUTS.
A 2019 Cochrane Review based on 1-year WATER trial results, found evidence of similar results with TURP to be of moderate-certainty related to the urologic symptom score (IPSS) primary outcome measure. All other metrics were graded low-certainty (QOL), to very low-certainly (adverse events, retreatments, erectile function, ejaculatory dysfunction). 3 Evidence was downgraded mainly due to study limitations (performance, reporting, and attrition bias), and imprecision (confidence intervals that crossed the assumed thresholds of clinically important differences or few events, or both). For example, both sexual outcome (erectile and ejaculatory function) results were downgraded 2 levels for a combination of imprecision and study limitations (high risk of performance and attrition bias). The authors recommend larger, more rigorously conducted, and transparently reported, studies comparing Aquablation ® to other techniques (laser enucleation, prostatic urethral lift, robotic-assisted simple prostatectomy) for which there is also increasing interest.
The contractor cites 36 sources in the bibliography; the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2020-12-27
- Current revision effective
- 2025-12-14
- Last reviewed by the contractor
- 2025-10-01
- MCD version
- 13
Other related documents: A60346 (Response to Comments).
Using this policy on a claim
Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the Wisconsin Physicians Service Insurance Corporation hub lists every other active policy from the same contractor.
The same policy title at other contractors
Contractors often adopt each other's policies and then revise them separately, so the criteria and the diagnosis lists drift apart. The topic comparison lines up every version.
Frequently asked questions
What does LCD L38682 cover?
Benign prostatic hyperplasia (BPH) is a histological diagnosis characterized by an increased number of epithelial and stromal cells in the prostate. It is common in men over the age of 40, and the incidence increases with age. In the United States, 8 million men older than 50 years old suffer from BPH. In many cases BPH is asymptomatic, however, symptoms may occur with prostate enlargement and compression of the… The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.
Which states does LCD L38682 apply to?
Wisconsin Physicians Service Insurance Corporation applies it to Medicare claims in AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.
Which diagnosis codes support medical necessity under LCD L38682?
The companion billing and coding article A58209 lists 1 ICD-10-CM codes in 1 group that support medical necessity; the first 1 appear on this page and the complete list is in the article on cms.gov.
How do I appeal a denial under LCD L38682?
The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database, current LCD exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file lcd.csvSHA-256 2fcc4251b6ddd1eb…
- Medicare Coverage Database, current Billing and Coding Articles exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file article.csvSHA-256 f31932f1df3b4035…
- ICD-10-CM FY2027 code descriptionsVersion FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…
Disclaimer
The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.