42821
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
4.25
Facility
$272.22
Non-Facility
$272.22
Documentation Required
- Use of appropriate diagnosis coding (policy references N39.44 - Nocturnal enuresis) and appropriate HCPCS (S8270 for enuresis alarm; J2597 for desmopressin injection) when selection criteria are met.
- Clinical notes supporting diagnosis of primary nocturnal enuresis (e.g., absence of daytime symptoms) and linkage to ICD-10 code N39.44 when applicable.
- Physician examination documenting that physical or organic causes for nocturnal enuresis (e.g., renal disease, neurological disease, infection) have been evaluated and ruled out.
- Documentation of the member's age (must be ≥7 years for bedwetting alarm; >5 years for desmopressin).
Key Coverage Criteria
- Use of a bedwetting alarm as durable medical equipment for the treatment of primary nocturnal enuresis when ALL of the following criteria are met: member is 7 years of age or older; member has experienced bedwetting a minimum of 3 nights a week in the previous month, or at least 1 wetting episode weekly for 1 year; member has no daytime wetting; member has been examined by a physician, and physical or organic causes for nocturnal enuresis (e.g., renal disease, neurological disease, infection, et [...]
- Desmopressin for the treatment of primary nocturnal enuresis in children older than 5 years whose bedwetting has not responded to non-pharmacologic therapies (e.g., fluid and food intake advice, enuresis alarm treatment), or when non-pharmacologic therapies were refused or the child is unlikely to adhere to enuresis alarm treatment.
- HCPCS J2597 (injection, desmopressin acetate) — covered if selection criteria for desmopressin are met.
- HCPCS S8270 (enuresis alarm, using auditory buzzer and/or vibration device) — covered if selection criteria for bedwetting alarm are met.
- ICD-10 code N39.44 (Nocturnal enuresis) — listed as a covered diagnosis when selection criteria are met.
- Continuous Positive Airway Pressure (CPAP) devices and accessories — HCPCS E0601 and listed masks/interfaces/accessories (A7027–A7046, A7037–A7039, E0561–E0562, etc.) covered for obstructive sleep apnea (G47.33) when selection criteria are met (AHI thresholds specified).
3 Active Policies
AETNA-CPB-0431 — Enuresis
AETNA-CPB-0004 — Obstructive Sleep Apnea in Adults
ANTHEM-CG-SURG-113 — CG-SURG-113 Tonsillectomy with or without Adenoidectomy for Adults
Related Codes
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