1.0 CPT PROCEDURE CODES
50010 - 53899, 64561, 64581,
64585, 64590, 64595, 0421T
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.
3.9 Transurethral
needle ablation (TUNA) (CPT code 53852) for the treatment of BPH
is proven.
3.10 Transurethral
waterjet ablation of the prostate (CPT code 0421T) for the treatment
of BPH is covered.
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.
5.5 January 1, 2020
for transurethral waterjet ablation of the prostate for the treatment
of BPH (CPT code 0421T).