L8604, Injectable bulking agent, dextranomer/hyaluronic acid copolymer implant,
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- 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.
Key Coverage Criteria
- 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.
10 Active Policies
AETNA-CPB-0534, Vesicoureteral Reflux Treatment by Endoscopic Injection of Bulking Agents
SUR710.022, Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux (VUR)
BCBSIL-SUR710.008, Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence
BCBSIL-SUR710.022, Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux (VUR)
BCBSMT-SUR710.008, Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.