0672T — Ndovag cryg rf remdl tiss
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Baseline and follow-up clinical history and physical examinations (recommended at 1, 3, 6, and 12 months).
- Urodynamic studies performed at baseline and during follow-up visits.
- Voiding diary and validated quality-of-life questionnaire completed by the patient.
- Objective outcome documentation: negative Valsalva maneuver defined as 'cure' and decreased daily pad use defined as 'improvement'.
Key Coverage Criteria
- Stress urinary incontinence (SUI) in women (involuntary urine loss with increased intra-abdominal pressure).
- Persistent SUI after failure of conservative therapy (pelvic floor muscle exercises, pessary devices, behavioral therapy, biofeedback, pelvic electrical stimulation, or periurethral bulking agents).
- Use of nonablative radiofrequency (RF) energy to shrink and stabilize the endopelvic fascia to improve support of the urethra and bladder neck for treatment of stress urinary incontinence (SUI).
- Procedure performed as outpatient using device-specific approaches such as the SURx® Transvaginal System or the Lyrette™ Transurethral SUI System (formerly Renessa).
- Indicated for shrinkage and stabilization of female pelvic tissue for treatment of Type II stress urinary incontinence (per FDA 510(k) clearance).
- Use of a cryogen-cooled monopolar radiofrequency vaginal probe to deliver RF energy intended to remodel tissue and achieve coagulation and/or hemostasis.
5 Active Policies
BCBSIL-SUR710.021 — Radiofrequency Energy Therapy for Stress Urinary Incontinence
BCBSMT-SUR710.021 — Radiofrequency Energy Therapy for Stress Urinary Incontinence
BCBSNM-SUR710.021 — Radiofrequency Energy Therapy for Stress Urinary Incontinence
BCBSOK-SUR710.021 — Radiofrequency Energy Therapy for Stress Urinary Incontinence
SUR710.021 — Radiofrequency Energy Therapy for Stress Urinary Incontinence
Related Codes
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