Medicare AdvantageCoverageMedium impact
MA11.004p, Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH)
Independence Blue Cross·Urology·Medical Policy
Effective date
Jul 28, 2025
We identified it
Jun 19, 2026
Summary
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.
Action Required
By July 28, 2025: (1) Billing team must update billing system and fee schedules to recognize CPT 55801 as medically necessary for Aquablation procedures on Independence Blue Cross Medicare Advantage plans. (2) Remove age 80 or younger restriction and transrectal ultrasound (TRUS) requirements from Aquablation authorization logic. (3) Update prior authorization workflows to remove voided volume greater than 125 cc requirement for Aquablation. (4) Reclassify CPT 37242 (prostate artery embolization) as experimental/investigational and remove CPT 53899 from billing records; flag any pending or submitted claims using 53899 for recoding to 37242 with notation of experimental status. (5) Update provider education materials to reflect policy title change and new coverage criteria. (6) Providers should verify Medicare Advantage member eligibility before Aquablation procedures, as coverage criteria have expanded. Failure to update billing system will result in claim denials or incorrect reimbursement for CPT 55801 and potential overpayment recovery for code 53899 claims.