CommercialCoverageHigh impact
Benign Prostatic Hyperplasia (CPB 0079, reviewed 2026-04-15)
Aetna·Urology, Internal Medicine, Geriatrics·Medical Policy
Effective date
Apr 15, 2026
We identified it
Aug 12, 2026
Summary
Aetna has updated its BPH treatment policy (CPB 0079) effective 2026-04-15, clarifying coverage for 15+ medically necessary treatment approaches including medications, minimally invasive procedures, and devices. The policy also specifies which procedures and tests are considered experimental/unproven and therefore not covered. Billing teams must update systems to reflect correct coverage status for common BPH procedures and ensure prior authorization requirements are applied where needed.
Action Required
By 2026-04-15, the billing team must: (1) Update the billing system to recognize the 15 medically necessary BPH treatment codes as covered procedures (52282, 52284, 52441-52443, 52450, 52597, 52601, 52648-52649, 53850, 53854-53855, 53865-53866, 37243) with appropriate authorization rules; (2) Flag the following codes as experimental/not covered in the system: 0655T, 0714T, 0867T, 0950T, 37242, 37244, and any claims for phytotherapy, HIFU, histotripsy, or genetic testing for BPH susceptibility; (3) Update prior authorization protocols to reflect UroLume requirements (age 60+ OR poor surgical candidate with prostate ≥2.5 cm) and iTind requirements (prostate volume 25-75g, no median lobe obstruction); (4) Communicate to providers that tadalafil coverage varies by individual plan—verify benefit details before billing; (5) Configure system to deny claims for experimental procedures listed in the policy or they will be rejected by Aetna as non-covered services. Urology team should be notified of coverage changes immediately.