1.0 CPT
PROCEDURE CODES
50010 - 53899, 64561, 64581,
64585, 64590, 64595
3.0 POLICY
3.1 Services
and supplies required in the diagnosis and treatment of illness
or injury involving the urinary system are covered.
3.2 Benefits
may be considered for the implantation of similar U.S. Food and
Drug Administration (FDA) approved devices. The Sacral Nerve Root
Stimulation (SNS) has received FDA approval. Services and supplies
related to the implantation of the SNS may be covered for individuals
with urge incontinence, non-obstructive urinary retention, or symptoms
of urgency-frequency syndrome that is not due to a neurologic condition,
who have failed previous conservative treatments, and who have had
a successful peripheral nerve evaluation test.
3.3 The use
of a bedwetting alarm for the treatment of primary nocturnal enuresis
may be considered for cost-sharing when prescribed by a physician
and after physical or organic causes for nocturnal enuresis have
been ruled out.
3.4 Collagen implantation of the
uretha and/or bladder neck may be covered for patients not amenable
to other forms of urinary incontinence treatment.
3.5 Cryoablation
for renal cell carcinoma (Current Procedural Terminology (CPT) procedure
codes 50250 and 50593) may be considered for coverage under the
Rare Disease policy (
Chapter 1, Section 3.1) on a case-by-case
basis. Effective June 1, 2006.
3.6 Under the provisions for the
treatment of rare diseases, coverage of laparoscopic Radiofrequency
Ablation (RFA) (CPT procedure code 50542) and Percutaneous Radiofrequency Ablation
(PRFA) (CPT procedure code 50592) may be considered on a case-by-case
basis for the treatment of Renal Cell Carcinoma (RCC) and genetic
syndromes associated with RCC including von Hippel-Lindau syndrome,
hereditary papillary cell carcinoma, or hereditary clear-cell carcinoma
for patients who are not appropriate candidates for surgical intervention.
3.7 Posterior Tibial Nerve Stimulation
(PTNS) for treatment of overactive bladder, to include urinary frequency,
urge, and incontinence (CPT code 64566) is proven.
3.8 Prostatic Urethral Lift (PUL)
for the treatment of urinary outflow obstruction secondary to Benign
Prostatic Hyperplasia (BPH) (CPT codes 52441, 52442; HCPCS codes
C9739, C9740) is proven.
4.0 EXCLUSIONS
4.1 Peri-urethral
Teflon injection is unproven.
4.2 Silastic gel implant.
4.3 Acrylic
prosthesis (Berry prosthesis).
4.4 Bladder stimulators, direct
or indirect, such as spinal cord, rectal and vaginal electrical stimulators,
or bladder wall stimulators. Payment for any related service or
supply, including inpatient hospitalization primarily for surgical
implementation of a bladder stimulator.
4.5 Transurethral balloon dilation
of the prostate (CPT procedure code 52510) is unproven.
4.6 Cryoablation
for the treatment of renal angiomyolipoma is unproven.
5.0 EFFECTIVE
DATE
5.1 Transurethral
Needle Ablation (TUNA) of the prostate is proven (CPT procedure
code 53852). Effective June 1, 2004.
5.2 March 28, 2007, for laparoscopic
RFA or PRFA for the treatment of RCC and genetic syndromes associated
with RCC, including von Hippel-Lindau syndrome, hereditary papillary
cell carcinoma, or hereditary clear-cell carcinoma.
5.3 December 9, 2014, for PTNS for
the treatment of overactive bladder.
5.4 September 16, 2015, for PUL for
the treatment of urinary outflow obstruction secondary to BPH.