Prostate Procedures for Benign Prostatic Hyperplasia Benefit Changes - Texas Medicaid Effective Oct. 1, 2021

What is New?
Per the Texas Medicaid and Healthcare Partnership (TMHP) , effective for dates of service on or after Oct. 1, 2021, prostate procedures for benign prostatic hyperplasia benefits criteria will change for Texas Medicaid.

Benefit Changes
Changes to this medical benefit include:

• Minimally invasive therapies
• Surgical procedures
• Laser procedures

Minimally Invasive Therapies (MIST) for BPH
    New Benefit: Prostatic Urethral Lift (PUL)

• Procedure Code: 52441
• Benefit: Limited to one service per lifetime for male clients 45 years of age or older
• Provider Type: Physician providers
• Place of Service: Office or outpatient hospital

• Procedure Code: 52442
• Benefit: Limited to six implants per lifetime for male clients 45 years of age or older
• Provider Type: Physician providers
• Place of Service: Office or outpatient hospital
• Prior Authorization: Required if more than six total implants are needed

• Procedure Code: C9739: First through third implant
• Procedure Code: C9740: Four or more subsequent implants
• Benefit: Limited to one service per lifetime for male clients 45 years of age or older
• Provider Type: Physician providers
• Place of Service: Ambulatory surgical center, providers for services rendered outpatient hospital

    New Benefit: Transurethral Needle Ablation (TUNA)

• Procedure Code: 53852
• Benefit: One surgical procedure per day, same procedure, same place of service
• Provider Type: Physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS), physician providers, ambulatory surgical center providers
• Place of Service: Office (surgery) or outpatient hospital (ambulatory surgical center)
• Note: This will not be reimbursed to any provider for services rendered in the inpatient hospital setting.

Surgery for BPH
    New Benefit: Transurethral Resection of Prostate (TURP)

• Procedure Code: 52601 - Initial procedure/if staged subsequent TURP performed must bill modifier 58
• Benefit: No longer will be limited to once per lifetime
• Provider Type: Physician providers
• Place of Service: Office or outpatient hospital

Holmium Laser Procedures for the Prostate
    Added Benefit:

• Procedure Code: 52649
• Provider Type: Physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS), physician providers, ambulatory surgical center providers
• Place of Service: Outpatient hospital (surgery) or inpatient and outpatient hospital (assistant surgery)
• Note: Assistant surgery procedure code 52649 requires prior authorization.

    Changed Benefit: Transurethral Microwave Thermotherapy (TUMT)

• Procedure Code: 53850
• Benefit: Age restriction updated to include ages 21 and older

    Changed Benefit: Rezum Water Vapor Therapy

• Procedure Code: 53854
• Benefit: Limited to male ages 21 and older. No reimbursement to any provider type for services rendered in the inpatient hospital setting

    Change Benefit: Temporary Urethral Stent

• Procedure Code: 53855
• Benefit: Expanding the benefit for assistant surgery for type of service, place of service and provider type
• Provider Type: Physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS), physician providers, ambulatory surgical center providers
• Place of Service: Office, inpatient and outpatient hospital (assistant surgery)

Have questions:
Contact our BCBSTX Medicaid Provider Service Center at 1-877-560-8055 or contact your BCBSTX Medicaid Provider Network Representative at 1-855-212-1615.

The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.

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