Medicare coverage for the TULSA-PRO system is in a transitional phase. As of January 1, 2025, CMS established Category 1 CPT codes specifically for the transurethral ultrasound ablation (TULSA) procedure, which is a significant step toward routine reimbursement. However, having billing codes does not guarantee that every Medicare beneficiary will receive coverage, and many patients still face denials or end up paying out of pocket.
What Changed in 2025
Before 2025, the TULSA procedure lacked its own dedicated billing codes, which made insurance reimbursement difficult. CMS changed that by assigning three Category 1 CPT codes effective January 1, 2025. These codes apply to all three settings where the procedure can be performed: hospital outpatient departments, ambulatory surgical centers, and private offices.
In the hospital outpatient setting, the national average reimbursement rate is approximately $9,209. In an ambulatory surgical center, it drops to about $7,195. These figures represent what CMS pays the facility, not what you would owe. Based on 2024 national averages, patient out-of-pocket costs under Medicare run roughly $1,630 to $1,640 when the procedure is covered in either a hospital outpatient or ambulatory surgical center setting.
Why Coverage Isn’t Guaranteed
Having CPT codes means Medicare can process and pay claims for the procedure, but it doesn’t mean every claim will be approved. There is currently no National Coverage Determination from CMS specifically addressing TULSA. That means coverage decisions often fall to regional Medicare Administrative Contractors, and their policies can vary. Without a clear national directive saying “this is covered for these indications,” individual claims may be evaluated case by case.
Several major private insurers, including Blue Cross Blue Shield of Michigan and Excellus BlueCross BlueShield, still classify TULSA as experimental or investigational for the treatment of localized prostate cancer. While Medicare operates under its own rules, these insurer positions reflect a broader pattern: the procedure’s evidence base is still being evaluated by many payers. If you have a Medicare Advantage plan (Medicare HMO), your plan may apply its own medical policy criteria when no national or local Medicare coverage decision exists.
What the Procedure Is Cleared For
The TULSA-PRO system received its most recent FDA clearance in May 2024 as a high-intensity ultrasound system for prostate tissue ablation. It uses MRI-guided focused ultrasound delivered through the urethra to heat and destroy targeted prostate tissue. The FDA clearance covers prostate tissue ablation broadly, which includes both cancerous and non-cancerous conditions like benign prostatic hyperplasia (BPH).
This distinction matters for coverage. A claim submitted for BPH treatment may be evaluated differently than one for prostate cancer. Some providers have reported more success obtaining reimbursement depending on the specific diagnosis and how the case is documented.
What You’ll Likely Pay Without Coverage
If Medicare or your insurer denies the claim, the total cost of the TULSA procedure ranges widely, from about $680 to nearly $13,000 depending on the center and what’s included. Some TULSA-PRO centers operate on a cash-pay-only basis, while others accept insurance and will work with you to determine coverage before scheduling. UCLA Health and other providers recommend selecting a TULSA-PRO center first, then having their reimbursement team investigate your specific policy before committing.
Appealing a Denial
If your claim is denied, appealing is worth the effort. Dr. Stephen Scionti, national medical director for Vituro Health (a network of TULSA-PRO providers), has described the current landscape as “a one-patient-at-a-time battle.” His organization runs a dedicated insurance reimbursement assistance program that helps patients file appeals after a denial, and they’ve had some early successes.
The appeal process typically involves submitting clinical documentation showing why the procedure was medically necessary for your specific case, along with supporting evidence from peer-reviewed studies. Each successful appeal creates precedent that makes the next approval slightly more likely. Most patients aren’t familiar with the appeals process, so working with a provider that has reimbursement expertise is a practical advantage.
How to Improve Your Chances of Coverage
Start by choosing a TULSA-PRO center that actively works with insurers rather than one that only accepts cash. These centers typically have reimbursement specialists on staff who understand how to code and document the procedure for the best chance of approval. Ask the center directly whether they’ve had success getting Medicare to pay for the procedure and what percentage of their patients receive some level of reimbursement.
Get a predetermination or prior authorization before the procedure whenever possible. This forces your insurer to make a coverage decision in advance, so you know what you’ll owe. If the answer is no, you can appeal before the procedure rather than fighting a bill afterward. Keep in mind that the new 2025 CPT codes are still fresh, and coverage patterns will likely shift as more claims are processed and more data on outcomes becomes available.