Stress urinary incontinence can result from intrinsic sphincter deficiency (ISD). Periurethral bulking agent is a material that is injected around the urethra that can assist in narrowing the urethra so leakage is less likely to occur.
Vesicoureteral reflux (VUR) is the retrograde flow of urine from the bladder upward toward the kidney. Bulking agents can be injected into tissue around the ureteral orifices to minimize reflux.
Urinary Stress Incontinence
The use of United States Food and Drug Administration (U.S. FDA) approved bulking agents for the treatment of urinary stress incontinence may be considered medically necessary in individuals who have failed appropriate conservative therapy for at least three (3) months.
Additional treatments for reoccurrence of stress urinary incontinence with a periurethral bulking agent may be considered medically necessary following successful treatment in the past six (6) to 12 months.
Further treatment of stress urinary incontinence with a bulking agent is considered not medically necessary when there is failure to improve after five (5) separate treatment sessions.
The use of bulking agents to treat stress urinary incontinence not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore, non-covered, because the safety and/or effectiveness of this service cannot be established by the published peer-reviewed literature including but not limited to the following:
51715 |
L8606 |
|
|
|
|
|
Urge Urinary Incontinence
The use of U.S. FDA approved periurethral bulking agents to treat urge urinary incontinence is considered not medically necessary.
L8604 |
|
|
|
|
|
|
Vesicoureteral Reflux
The use of U.S. FDA approved periureteral bulking agents for the treatment of pediatric individuals with VUR grades II, III, or IV may be considered medically necessary when medical therapy has failed, and surgical intervention is otherwise indicated.
The use of periurethral bulking agents for VUR not meeting the criteria as indicated in this policy is considered not medically necessary.
52327 |
L8604 |
|
|
|
|
|
The use of bulking agents is contraindicated in individuals with:
American Urological Association et al - 2017
The 2017 joint guidelines on surgical treatment of female stress urinary incontinence from the American Urological Association and Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction stated that bulking agents are an option for patients considering surgery for stress urinary incontinence (SUI). The guidelines also stated that there are few long-term data on the efficacy of bulking agents and that retreatment is common.
In 2017, the American Urological Association reviewed and confirmed the validity of its 2010 published guideline on the management of primary VUR in children. The Association recommended that [individuals] older than one (1) year of age who have a febrile breakthrough urinary tract infection while receiving continuous antibiotic prophylaxis be considered for open surgery or endoscopic injection of bulking agents.
Covered Diagnosis Codes for 51715, L8606
N36.42 |
N36.43 |
N39.3 |
|
Covered Diagnosis Codes for 52327, L8604
N11.0 |
N13.70 |
N13.71 |
N13.72 |
N13.721 |
N13.722 |
N13.729 |
N13.73 |
N13.731 |
N13.732 |
N13.739 |
|
|
|
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract, and subject to the applicable laws of your state.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you need these services, contact the Civil Rights Coordinator.
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
