53454
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
- Documentation that the patient is motivated and has sufficient manual dexterity to operate the AUS device.
- For post-prostatectomy patients considered for AUS, documentation of at least 6 to 12 months since prostate surgery and documentation that behavioral and pharmacologic therapies were tried prior to AUS placement.
- When reporting outcomes of diagnostic TPUS, include details of bladder volume, description of Valsalva maneuver, and relevant comparative data such as cough test or urodynamic findings when available (studies cited use urodynamic cough testing as reference standard).
- For interventions described as investigational (stem cell injections, vaginal laser therapy, moxibustion, gene testing for SUI), documentation should include that these are being performed in the context of research or that the patient was informed of the investigational/experimental status (policy text emphasizes lack of sufficient high-quality evidence and need for further trials).
Key Coverage Criteria
- Multi-channel urodynamic studies are medically necessary when the member has both symptoms and physical findings of urinary incontinence/voiding dysfunctions (such as stress incontinence, overactive bladder, lower urinary tract symptoms) and there is consideration by the provider to perform invasive, potentially morbid or irreversible treatments after conservative management has been tried and failed.
- Artificial urinary sphincter (AUS) implantation is medically necessary for urinary incontinence due to intrinsic urethral sphincter deficiency (IUSD) in members with any of the following indications: Children with intractable UI due to IUSD who are refractory to behavioral or pharmacological therapies and are unsuitable candidates for other types of surgical procedures for correction of UI.
- Artificial urinary sphincter is medically necessary for members who are 6 or more months post-prostatectomy who have had no improvement in the severity of UI despite trials of behavioral and pharmacological therapies.
- Artificial urinary sphincter is medically necessary for members with epispadias-exstrophy in whom bladder neck reconstruction has failed.
- Artificial urinary sphincter is medically necessary for women with intractable UI who have failed behavioral, pharmacological, and other surgical treatments.
- Periurethral injections of FDA-cleared bulking agents (examples: Bulkamid, Coaptite, Contigen, Durasphere, Macroplastique, Uryx) are medically necessary for management of UI resulting from intrinsic sphincter deficiency refractory to conservative management (e.g., Kegel exercises, biofeedback, electrical stimulation, and/or pharmacotherapies).
3 Active Policies
AETNA-CPB-0223 — Urinary Incontinence
ANTHEM-SURG.00010 — SURG.00010 Treatments for Urinary Incontinence
REGENCE-MED176 — Periurethral Transperineal Adjustable Balloon Continence Device
Related Codes
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