Medicare AdvantageBilling CodesHigh impact
MA11.004q, Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH)
Independence Blue Cross·Urology·Medical Policy
Effective date
Jan 1, 2026
We identified it
Jun 19, 2026
Summary
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.
Action Required
By 12/31/2025: Billing team must update billing system edits and fee schedules to reflect CPT code changes effective 01/01/2026. (1) Add CPT 52597 to medically necessary procedures for BPH treatment under Medicare Advantage plans. (2) Add CPT 52443 to experimental/investigational category—flag for prior authorization review and potential denial. (3) Designate CPT 53899 as not medically necessary—configure system to reject or deny claims with this code. (4) Delete CPT 52647, 0421T, and 0619T from billing system entirely—these codes are no longer covered and should not be billed. (5) Verify that all BPH procedures meet the five medical necessity criteria listed in the policy (appropriate treatment type, age 45+, qualifying BPH condition, PSA testing within 12 months meeting thresholds, and peak urine flow rate ≤12 cc/sec). (6) Update encounter forms and coder instructions to reflect new code status. Failure to implement these changes will result in claim denials for procedures billed with deleted or incorrectly categorized codes.