Humana·IA, KS, MO, NE, IN, MI, IL, MN, WI, CT, MA, ME, NH, NY, RI, VT, KY, OH, CA, HI, NV, AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY, AR, CO, LA, MS, NM, OK, TX, DE, DC, MD, NJ, PA, AL, GA, TN, NC, SC, VA, WV, FL, PR · Urology, General Surgery·Medicare Advantage
Effective date
Sep 1, 2026
We identified it
Aug 28, 2026
Days to comply
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Summary
This is a comprehensive Medicare Advantage coverage policy for Benign Prostatic Hyperplasia treatments effective September 1, 2026. The policy outlines coverage determinations for multiple BPH treatment modalities including surgical procedures (TURP, prostatectomy, laser therapies), temporary implanted devices, stents, and diagnostic testing. The policy references multiple MAC-specific Local Coverage Determinations (LCDs) that vary by geographic jurisdiction, requiring billing teams to verify applicable coverage rules based on patient location.
Action Required
Action needed
By August 1, 2026: Billing team must complete the following actions: (1) Identify all applicable Medicare Administrative Contractor (MAC) jurisdiction rules for your practice's patient locations using the geographic mapping provided in the policy (pages 2-3); (2) Review the MAC-specific LCDs for your jurisdiction(s) - particularly for Transurethral Waterjet Ablation (L38682, L38367, L38378, L38705, L38712, L38549, L38726), Fluid Jet System (L38367), Laser Ablation (L34090), Rezum System (A56083), and Urodynamics testing (L33576, L34056, A57455, A56802); (3) Update billing system and encounter forms to reflect coverage rules specific to each MAC jurisdiction; (4) Establish pre-authorization workflows for BPH procedures that require prior approval under applicable LCDs; (5) Train clinical and billing staff on diagnostic testing requirements (post-void residual measurement, urinalysis, cystoscopy, ultrasonography, urodynamic and uroflowmetry testing as clinically indicated); (6) Configure billing software to flag claims for procedures performed in states/territories not covered by your primary MAC for manual review. Failure to apply correct MAC-specific rules will result in claim denials and payment delays. Verify LCD applicability BEFORE service delivery.