N40.1 Insurance Policy Changes

ICD-10 N40.1 is officially defined as "Benign prostatic hyperplasia with lower urinary tract symptoms." code N40.1 is referenced in 17 tracked payer policy changes from Independence Blue Cross, Health Net, and 3 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code N40.1 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Independence Blue Cross · Effective Jan 1, 2026High impact
MA11.004q, Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH)
Independence Blue Cross Medicare Advantage updated policy MA11.004q to MA11.004r effective 01/01/2026, adding CPT 52597 (robotic waterjet resection) as medically necessary, CPT 52443 (experimental/investigational), removing CPT 52647, 0421T, and 0619T, and designating CPT 53899 as not medically necessary. Billing teams must update systems to reflect these code changes and ensure claims comply with the new coverage status.
Independence Blue Cross · Effective Jan 1, 2026High impact
11.17.06w, Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH)
Independence Blue Cross updated policy 11.17.06w to 11.17.06x, effective 01/01/2026, adding new CPT code 52597 (robotic-assisted waterjet resection) as medically necessary, designating CPT 52443 as experimental/investigational, marking CPT 53899 as not medically necessary, and deleting three codes (52647, 0421T, 0619T). Billing teams must update systems to reflect these code status changes immediately upon the effective date.
Independence Blue Cross · Effective Jul 28, 2025High impact
11.17.06v, Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH)
Independence Blue Cross updated policy 11.17.06v to 11.17.06x, removing age and prostate volume restrictions for Aquablation (water-jet hydrosection) procedures, adding CPT 55801 as medically necessary, and reclassifying prostate artery embolization (PAE) code 37242 as experimental/investigational while removing code 53899.
Health Net · Identified Jun 20, 2026High impact
21-139 Medical Policies - 4th Quarter 2020
Health Net updated multiple medical policies in Q4 2020, affecting prior authorization requirements, coverage criteria, and billing codes across numerous specialties including oxygen therapy, allergy testing, bariatric surgery, wound care, and various diagnostic procedures.
Health Net · Identified Jun 20, 2026High impact
21-141 Medical Policies - 4th Quarter 2020
Health Net updated multiple medical policies in Q4 2020, affecting prior authorization requirements, coverage criteria, and billing codes across numerous specialties including oxygen therapy, allergy testing, bariatric surgery, and wound care. Most changes involve revised medical necessity criteria and updated CPT/ICD-10 codes that require immediate attention for proper billing and authorization processes.
Health Net · Identified Jun 20, 2026High impact
21-142 Medical Policies - 4th Quarter 2020
CalViva Health updated multiple medical policies for Q4 2020 affecting prior authorization requirements, coverage criteria, and billing codes across numerous specialties. Key changes include revised oxygen therapy criteria, new ambulatory surgery center redirection requirements, updated bariatric surgery protocols, and modified coverage for various diagnostic and therapeutic services.
Independence Blue Cross · Effective Sep 21, 2026Medium impact
MA11.004r, Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH)
Independence Blue Cross Medicare Advantage updated policy MA11.004r to classify the permanent nitinol urethral expansion device (ProVee System) and CPT code 52282 as Experimental/Investigational, effective 09/21/2026. This means claims for this device will not be covered or reimbursed. All other covered surgical and minimally invasive BPH treatments remain medically necessary when criteria are met.
Independence Blue Cross · Effective Sep 21, 2026Medium impact
11.17.06x, Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH)
Independence Blue Cross updated policy 11.17.06x to classify the ProVee System (permanent nitinol urethral expansion device) and CPT code 52282 as Experimental/Investigational for BPH treatment, effective 09/21/2026. This means claims for this device will not be covered. The policy continues to cover established surgical and minimally invasive treatments (TURP, laser procedures, UroLift, etc.) when medical necessity criteria are met.
Excellus BlueCross BlueShield · Effective Oct 16, 2025Medium impact
Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) 7.01.104
Excellus BlueCross BlueShield policy 7.01.104 covers minimally invasive BPH treatments, including prostatic urethral lift, water vapor thermal therapy, Aquablation and prostate artery embolization, when symptomatic BPH is present and device-specific criteria are met, and it lists prostate artery embolization as changed from investigational to medically appropriate for specific indications in its October 16, 2025 update. Transperineal laser ablation, the temporary implantable nitinol device (iTIND) and drug-coated balloons such as Optilume are considered investigational. The policy history also records an 08/04/26 policy edit that updated the professional guidelines section to reflect the 2026 AUA update and changed the prostate artery embolization grade from C to B.
Independence Blue Cross · Effective Jul 28, 2025Medium impact
MA11.004p, Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH)
Independence Blue Cross updated Medicare Advantage policy MA11.004r (effective 07/28/2025) for BPH surgical treatments, removing age and prostate volume restrictions for Aquablation procedures, adding CPT 55801 as medically necessary, and reclassifying prostate artery embolization code 37242 as experimental/investigational (replacing 53899). The policy title now includes 'Surgical' treatments alongside minimally invasive options.
Independence Blue Cross · Effective Jul 1, 2025Medium impact
11.17.06u, Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH)
Independence Blue Cross updated policy 11.17.06u to 11.17.06x effective July 1, 2025, adding CPT code 0950T and removing CPT code 53899 for surgical and minimally invasive BPH treatments. Billing teams must update systems to recognize the new code and discontinue use of the removed code to prevent claim denials.
Aetna · Identified Oct 23, 2026Medium impact
Benign Prostatic Hyperplasia (CPB 0079, reviewed 2026-10-15)
Aetna's Clinical Policy Bulletin 0079 on benign prostatic hyperplasia (BPH), reviewed 2026-10-15, states that Aetna considers several treatments medically necessary for members with BPH as alternatives to transurethral resection of the prostate (TURP), including alpha adrenergic blockers, hormonal manipulation, laser-based procedures, Aquablation, prostatic urethral lift, prostatic arterial embolization and temporary implanted prostatic devices such as the iTind. It lists other approaches, such as absolute ethanol injection, botulinum toxin, high-intensity focused ultrasound, histotripsy and mirabegron, as experimental, investigational, or unproven, and it sets selection criteria and code-level coverage limits for several services.
Aetna · Identified Aug 16, 2026Medium impact
Sipuleucel-T (Provenge) (CPB 0802, reviewed 2025-12-22)
Aetna's Clinical Policy Bulletin 0802 covers sipuleucel-T (Provenge) for commercial medical plans, and Medicare criteria are in a separate policy. Aetna considers one course of sipuleucel-T, a total of 3 doses, medically necessary for metastatic castrate-resistant (hormone-refractory) prostate cancer in members who are asymptomatic or minimally symptomatic, have ECOG performance status 0 or 1, and do not have liver metastases, and therapy is limited to one course. Aetna considers all other indications experimental, investigational, or unproven, including prevention of prostate cancer, stage I to III prostate cancer, localized prostate cancer, and administration of more than 3 complete doses.
Aetna · Identified Aug 12, 2026Medium impact
Benign Prostatic Hyperplasia (CPB 0079, reviewed 2026-04-15)
For benign prostatic hyperplasia (BPH), alpha blockers, finasteride, dutasteride, tadalafil (5 mg daily), prostatic urethral lift, prostatic arterial embolization, Aquablation, laser prostatectomy, TUVP, TUIP, TUMT and TUNA are medically necessary alternatives to transurethral resection of the prostate (TURP). Temporary implanted prostatic devices such as the iTind are medically necessary when prostate volume is between 25 and 75 g and there is no obstruction in the median lobe, and UroLume is medically necessary for men at least 60 years old, or under 60 and poor surgical candidates, whose prostates are at least 2.5 cm long. Absolute ethanol injection, botulinum toxin, cryosurgical ablation, high-intensity focused ultrasound, histotripsy, melatonin, mirabegron and phytotherapy are listed as experimental, investigational or unproven for BPH.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Transurethral Microwave Thermotherapy (TUMT)
Transurethral microwave thermotherapy for benign prostatic hyperplasia may be considered medically necessary for patients who, based on the severity of their BPH symptoms, would be candidates for transurethral resection of the prostate. The treatment is not suitable for patients who have median lobe enlargement, bladder neck stenosis, or a prostate that does not meet the size recommendations for the device used, including prostatic urethra length and gland volume. The covered codes are CPT 53850, ICD-10 procedure codes 0V507ZZ and 0V508ZZ, and ICD-10 diagnosis code N40.1.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Saturation Biopsy for Diagnosis, Staging, and Management of Prostate Cancer
Saturation biopsy of the prostate, taking 20 or more core tissue samples at one time, is considered medically necessary in the diagnosis, staging, and management of prostate cancer. For Federal Employee Program (FEP) subscribers, the same procedure is considered investigational. The policy history records a 09/11/2025 review with no changes to the policy statement.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Prostatic Urethral Lift
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 listed criteria are met. Use of prostatic urethral lift in other situations, including repeat procedures, is considered investigational.

Watch N40.1

Get one email when a payer policy names N40.1, a payer adds or drops it from a prior auth list, or Medicare changes its NCCI pairs, unit limit, payment or coverage articles.

No account needed. We send a confirmation link first, and every email has a one-click stop link.

FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code N40.1?

There are 17 tracked policy changes affecting code N40.1, including updates from Independence Blue Cross, Health Net, Excellus BlueCross BlueShield. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code N40.1?

Payers that have issued tracked updates for code N40.1 include: Independence Blue Cross, Health Net, Excellus BlueCross BlueShield, Aetna, Blue Cross & Blue Shield of Mississippi.

How do I get notified when code N40.1 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code N40.1. You will get an email when new policy changes reference this code: daily or weekly, your choice, on every plan.

Why do payers change policies for code N40.1?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

All billing codes J3590 C9399 J3490 99215 99213 99202

Get alerts for changes like this

Save a search and get email alerts when a new policy change matches your filters: daily or weekly, your choice, on every plan.

Create a free alert How Policy Monitoring works

MA11.004q, Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH)

11.17.06w, Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH)

11.17.06v, Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH)

21-139 Medical Policies - 4th Quarter 2020

21-141 Medical Policies - 4th Quarter 2020

21-142 Medical Policies - 4th Quarter 2020

MA11.004r, Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH)

11.17.06x, Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH)

Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) 7.01.104

MA11.004p, Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH)

11.17.06u, Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH)

Benign Prostatic Hyperplasia (CPB 0079, reviewed 2026-10-15)

Sipuleucel-T (Provenge) (CPB 0802, reviewed 2025-12-22)

Benign Prostatic Hyperplasia (CPB 0079, reviewed 2026-04-15)

Transurethral Microwave Thermotherapy (TUMT)

Saturation Biopsy for Diagnosis, Staging, and Management of Prostate Cancer

Prostatic Urethral Lift

What insurance policy changes affect code N40.1?

Which payers have updated policy for code N40.1?

How do I get notified when code N40.1 policy changes?

Why do payers change policies for code N40.1?