1.0 CPT 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 United States (US) 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) 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 code 50542) and Percutaneous
Radiofrequency Ablation (PRFA) (CPT 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; Healthcare Common Procedure Coding System (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 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 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.