Does L8604 require prior authorization?

No, L8604 does not require prior authorization (high confidence). Code is covered without prior authorization.

`L8604` — Injectable bulking agent, dextranomer/hyaluronic acid copolymer implant, urinary tract, 1 ml, includes shipping and necessary supplies

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

For post-transplant cases: documentation of symptomatic VUR after renal transplantation and relevant transplant/graft function data.
Documentation of number of endoscopic injection treatment sessions and treatment response; if no improvement after 3 sessions, further treatments are not considered medically necessary.
Appropriate coding documentation linking procedure codes (e.g., CPT 52327) to covered diagnosis codes (ICD-10 N13.70–N13.9) and to the clinical justification meeting the selection criteria.
Documentation of failure of conservative treatments (e.g., prophylactic antibiotics and clean intermittent catheterization) prior to endoscopic injection.

Endoscopic injection of dextranomer/hyaluronic acid copolymer (Deflux), polydimethylsiloxane (Macroplastique), polytetrafluoroethylene (Teflon), or other bulking agents approved by the U.S. Food and Drug Administration (FDA) for vesicoureteral reflux (VUR) is medically necessary for the treatment of members with primary or secondary VUR who have any of the following conditions when conservative treatments (e.g., prophylactic antibiotics and clean intermittent catheterization) have failed:
Members with primary VUR (when conservative treatments have failed).
Members with secondary VUR (when conservative treatments have failed).
Children who have had a previously unsuccessful ureteral re-implantation.
Children who have stopped taking their medication as a result of drug intolerance or parental non-compliance.
Children whose reflux is associated with a thick-walled neuropathic bladder.

AETNA-CPB-0534 — Vesicoureteral Reflux Treatment by Endoscopic Injection of Bulking Agents

BCBSIL-SUR710.022 — Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux (VUR)

BCBSMT-SUR710.022 — Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux (VUR)

BCBSNM-SUR710.022 — Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux (VUR)

BCBSOK-SUR710.022

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