Medicaid Billing for Treatment of the Prostate

Highmark Wholecare’s Medicaid plan may cover a Prostatic Urethral Lift (PUL) system if it is deemed medically necessary to treat urinary flow obstruction caused by benign prostatic hyperplasia (BPH). If it is medically necessary, coverage will be provided under the Medicaid medical-surgical benefits.

Highmark Wholecare’s Treatment of the Prostate Clinical Medical Policy is designed to address medical necessity guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person’s unique clinical circumstances warrant individual consideration, based upon review of applicable medical records. 

Coding and Diagnosis Requirements

A variety of minimally invasive therapies and surgeries are available for treatment of enlarged prostates. This policy details the procedures that may be covered if following the criteria and diagnosis requirements outlined for medical necessity. The policy also specifies which treatments are considered experimental or investigational and are therefore non-covered because the safety or effectiveness of the service cannot be established. Due to the volume of procedure and diagnosis codes, please reference this policy for the list of services and conditions that are considered medically necessary.

To prevent claims from being rejected unnecessarily, please be sure to refer to these policy guidelines and resources when billing Medicaid Prostate Treatment Services. Highmark Wholecare monitors claims billing and payments to comply with federal and state requirements. Identified overpayments are required to be refunded to Highmark Wholecare. As a reminder, CMS requires providers to perform Self-Audits when issues are identified as well as on an on-going basis to ensure compliance.