52250
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
4.38
Facility
$211.76
Non-Facility
$211.76
Documentation Required
- No specific documentation requirements or required medical records/test results are specified in this CPB. (The policy primarily identifies tests/procedures considered obsolete/not covered and lists associated CPT/HCPCS/ICD-10 codes.)
Key Coverage Criteria
- None specified. This Clinical Policy Bulletin addresses obsolete and unreliable tests and procedures and lists tests/procedures that Aetna considers experimental and investigational (i.e., not covered).
- Verification of suprapubic catheter placement;or
- Removal of indwelling ureteral stents not amenable to office-based procedure;or
- Lower genital tract trauma with suspicion of urinary tract involvement, including urethral stricture;or
- Urine dribbling post voiding (for example, from a urethral diverticulum);or
- Injection of therapeutic agents for urinary incontinence;or
2 Active Policies
AETNA-CPB-0438 — Obsolete and Unreliable Tests and Procedures
ANTHEM-CG-SURG-51 — CG-SURG-51 Outpatient Cystourethroscopy
Related Codes
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