N99.3 — Prolapse of vaginal vault after hysterectomy
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- If MR defecography is proposed, documentation must address the reasons for choosing MR (note: MR defecography is considered investigational for CPB-listed indications and MR-related CPTs are listed as not covered for CPB indications).
- Documented chronic constipation as defined in the policy: presence of 2 or more of the following symptoms for at least 3 months: 'Lumpy and/or hard stools at least 1/4 of the time; or Sensation of incomplete evacuation at least 1/4 of the time; or Straining at defecation at least 1/4 of the time; or Two or fewer bowel movements per week.'
- Results of anorectal manometry and rectal balloon expulsion test demonstrating negative or inconclusive findings (these tests must have been performed prior to defecography per policy).
- Clinical documentation (history/physical, clinical notes, referral) showing suspicion of one or more of the specific causes of impaired defecation listed in the policy: anterior rectocele, enterocele, inappropriate contraction of the puborectalis muscle, or pelvic organ prolapse.
Key Coverage Criteria
- Inappropriate contraction of the puborectalis muscle.
- Pelvic organ prolapse.
- Covered CPT code (if selection criteria are met): 74270 (Radiologic examination, colon; barium enema, with or without KUB).
- ICD-10 codes covered if selection criteria are met:
- K59.00 - K59.09 (Constipation) [policy notes: not covered for routine evaluation; covered only if selection criteria met].
- K59.4 (Anal spasm [proctalgia fugax] [inappropriate contraction of the puborectalis muscle]).
2 Active Policies
AETNA-CPB-0718 — Defecography
ANTHEM-CG-MED-84 — CG-MED-84 Non-Obstetric Gynecologic Duplex Ultrasonography of the Abdomen and Pelvis in the Outpatient Setting
Related Codes
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