Does Medicare Cover Aquablation?

Aquablation therapy is a new surgical treatment that the FDA approved in December 2017. It addresses Benign Prostatic Hyperplasia (BPH).

This treatment is the first to be FDA-approved for the use of a surgical robot. The robot operates by automatically resectioning tissue to treat lower urinary tract symptoms caused by BPH.

If this is a treatment that could help you or a loved one, a common question you likely have is, “does Medicare cover Aquablation?”

In this article, we answer the question in clear, plain English.

Does Medicare Cover Aquablation?

The short answer is yes. Medicare will cover the cost of Aquablation. But not 100% of the time. As is often the case with Medicare, certain conditions have to be met for Medicare to pay for your Aquablation.

First, let’s take a look at what Aquablation therapy is. Then we will examine what conditions you have to meet in order to get coverage for Aquablation.

What Is Aquablation Therapy?

Aquablation therapy is a unique treatment. It’s the only technique that combines a camera with ultrasound imaging to allow the surgeon to examine the entire prostate in real-time. Next, it uses a heat-free waterjet controlled by robotic technology to remove prostate tissue.

Lower urinary tract symptoms (LUTS) caused by BPH are proven to be safely and successfully treated with Aquablation.

Original Medicare Coverage

Original Medicare (Medicare Part A and Part B) provides coverage for Aquablation. However, as with most things, Original Medicare only provides coverage for your Aquablation that they consider “medically necessary.” Your healthcare provider must first order the operation for Original Medicare to provide coverage.

In November 2020, the government announced that both Original Medicare and Medicare Advantage plans would provide reimbursement for Aquablation to treat Benign Prostatic Hyperplasia.

In other words, Original Medicare will often provide coverage for Aquablation treatment for BPH. However, coverage for Aquablation is still based on a case-by-case basis.

One of the main factors that determines whether or not you get coverage is where you live.

So where is it approved?

For example, in November 2020, only 12 states had approved Medicare Coverage for Aquablation treatment. Then later in December 2020, the remaining 38 states approved coverage for this treatment.

Conditions Required for Medicare Coverage

Original Medicare will provide coverage for treatments for BPH, including Aquablation, if you meet the following conditions:

You have a prostate volume of 30-150 cc by transrectal ultrasound
You experience persistent moderate to severe symptoms
The FDA approves the treatment

Plans A and B do not require prior authorization for them to provide coverage for Aquablation treatment for BPH. Next, let’s examine Medicare Advantage plans coverage.

Medicare Advantage Coverage

Medicare Advantage plans (Medicare Part C) also provide coverage for Aquablation. These plans have to cover everything Original Medicare covers. However, they will also offer some additional benefits as well.

What a plan covers and how much the out-of-pocket costs vary depending on your plan’s specifics.

Note: Medicare coverage changes all the time. And your specific coverage may vary from plan to plan for Medicare Advantage. Always be sure to double check with your health care provider and/or Medicare insurance provider about what your plan covers and what it does not.