N21.9 — Calculus of lower urinary tract, unspecified
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- 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
- Outpatient cystourethroscopy is consideredmedically necessaryforanyof the following indications:
1 Active Policy
ANTHEM-CG-SURG-51 — CG-SURG-51 Outpatient Cystourethroscopy
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