Notification of Policy Revisions Effective October 1, 2024 (Posted July 31, 2024)

Medical Policy	Revision
Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation (Aquablation) for Benign Prostatic Hyperplasia (PDF)	Title changed from “Transurethral Water Vapor Thermal for Benign Prostatic Hyperplasia” to “Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation (Aquablation) for Benign Prostatic Hyperplasia”. Description section updated. Regulatory Status updated. Policy statement updated to include coverage criteria for Transurethral Water Jet Ablation. Policy Guidelines updated. Codes 0421T and C2596 added to Billing/Coding section. References updated. Medical Director review 6/2024. Policy noticed 07/31/2024 for Effective date 10/01/2024

Medical Policy

Revision

Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation (Aquablation) for Benign Prostatic Hyperplasia (PDF)

Title changed from “Transurethral Water Vapor Thermal for Benign Prostatic Hyperplasia” to “Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation (Aquablation) for Benign Prostatic Hyperplasia”. Description section updated. Regulatory Status updated. Policy statement updated to include coverage criteria for Transurethral Water Jet Ablation. Policy Guidelines updated. Codes 0421T and C2596 added to Billing/Coding section. References updated. Medical Director review 6/2024. Policy noticed 07/31/2024 for Effective date 10/01/2024

Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.

Information in other languages: Español 中文 Tiếng Việt 한국어 Français العَرَبِيَّة Hmoob ру́сский Tagalog ગુજરાતી ភាសាខ្មែរ Deutsch हिन्दी ລາວ 日本語

© 2024 Blue Cross and Blue Shield of North Carolina. ®, SM Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. All other marks and names are property of their respective owners. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.