Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux (VUR)

Periureteral bulking agent injection is covered for treatment of vesicoureteral reflux (VUR)—typically grades II–IV—as an alternative to open surgical correction, primarily in pediatric patients after appropriate evaluation (e.g., following febrile UTI or abnormal renal/bladder imaging). Coverage is limited to cases where surgery would otherwise be indicated and excludes use in patients with nonfunctioning kidney(s), active voiding dysfunction, ongoing UTI, or Hutch diverticulum; other uses are considered experimental, and VCUG is not routinely recommended after a first febrile UTI in infants 2–24 months.

"Periureteral bulking agents for treatment of vesicoureteral reflux (VUR) grades II-IV when open surgical intervention is otherwise indicated."

Sign up to see full coverage criteria, indications, and limitations.