00117
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Key Coverage Criteria
- Injection of periurethral bulking agents is consideredmedically necessarywhen the individual has stress urinary incontinence (SUI) meeting one the following two criteria (A or B):
- The incontinence is due to trauma or injury;or
- Both of the following are true (1 and 2):
- The incontinence persists despite conservative treatment for at least a sufficient duration to fully assess treatment effect*;and
- One of the following is true:The incontinence is caused by intrinsic sphincter deficiency (ISD),orThe incontinence is due to urethral hypermobility in individuals with abdominal leak point less than 100 cm H2O.
- The incontinence is caused by intrinsic sphincter deficiency (ISD),or
2 Active Policies
ANTHEM-SURG.00010 — SURG.00010 Treatments for Urinary Incontinence
ANTHEM-MP-B094276 — TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow Products
Related Codes
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