The appropriate indication for the use of any one of these three types of thermotherapy is the treatment of outlet obstruction caused by BPH. The following two specific indications must be met:
  • BPH of sufficient degree to cause the following:
    • A peak urine flow of 15 cc per second or less in a voided volume of 125 cc or more.
    • A prostatic volume of less than 120 cc, as measured by transrectal ultrasound.
    • An American Urological Association (AUA) symptom score of 11 or higher.
    • A failed trial of alpha-adrenergic receptor blocker medication (used to restore satisfactory voiding) or intolerance to such medication.

  • A prostatic length that complies with the FDA certification of the designated treatment catheter length.
In addition, one or more of the following indications may apply:
  • Where preservation of erectile competence is of high importance to the patient.
  • Where co-factors such as cardiac disease, pulmonary conditions or other situations such as electrolyte problems or significant bleeding – as is possible with TURP – would pose a significant risk to the patient.
  • Prostate cancer.
  • Untreated bladder cancer. Where there is a previous history of treated bladder cancer, documentation should indicate that the patient is on an appropriate treatment regimen.
  • Prostate gland with an obstructive median lobe.
  • Neurogenic bladder and bladder dyssynergia, unless documented urodynamic studies indicate the existence of physical obstruction, ablation of which would result in clinical benefit.
  • Untreated cystolithiasis, gross hematuria, untreated urethral stricture or bladder neck contracture, acute prostatitis or diabetes mellitus affecting bladder function. Note that cystolithiasis, urethral stricture and bladder neck contracture may be treated at the same operative session, in which case a MIST procedure would not be contraindicated.
  • Active urinary tract infection.
  • The presence of a pacemaker or hip implant in the case of microwave therapies.
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
  • Safe and effective.
  • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
  • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient’s medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient’s medical need.
    • At least as beneficial as an existing and available medically appropriate alternative.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
13X, 18X, 21X, 83X, 85X
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances, Revenue Codes are purely advisory; unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/orRevenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual Publication 100-04, Claims Processing Manual, for further guidance.
036X, 045X, 049X, 0510, 076X
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
Prostatic microwave thermotx
Prostatic rf thermotx
Unlisted procedure, male genital system
Note: Use 55899 to represent Water-Induced Thermotherapy (WIT).
ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS codes 53850, 53852 and 55899 (WIT):
Covered for:
Hypertrophy (benign) of prostate
Nodular prostate
Benign localized hyperplasia of prostate
Cyst of prostate
Hyperplasia of prostate, unspecified
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
Diagnoses That Support Medical Necessity
ICD-9-CM Codes That DO NOT Support Medical Necessity
Diagnoses That DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.
Documentation Requirements
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
Utilization Guidelines
Sources of Information and Basis for Decision
J4 (CO, NM, OK, TX) MAC Integration
TrailBlazer adopted, unchanged, the TrailBlazer LCD, “Thermotherapies (MISTs) for Benign Prostatic Hyperplasia (BPH),” for the Jurisdiction 4 (J4) MAC transition.
Full disclosure of information sources is found with original contractor LCD.