Anthem Blue Cross California Outpatient Cystourethroscopy Form

Subject:

Description

This document addresses cystourethroscopy in the outpatient setting.

Clinical Indications

Medically Necessary:

Outpatient cystourethroscopy is considered medically necessary for any of the following indications:

1. Gross hematuria without evidence of glomerular disease or infection; or
2. Gross hematuria with blood clots; or
3. Microscopic hematuria without evidence of glomerular disease, infection, or known cause of hematuria and there is an increased risk for malignancy; or
4. Management of kidney stones unlikely to pass spontaneously; or
5. Suspected surgical urinary tract injury or foreign body (for example, injury to the ureter, incision into the bladder, intravesical placement or erosion of mesh or suture); or
6. Urinary urgency, urinary frequency, or urgency incontinence when there is no urinary tract infection (this also includes stress urinary incontinence); or
7. Suspected malignant involvement of the urinary tract (including diagnosis and staging of bladder cancer, as well as diagnosis and staging of cervical, endometrial, ovarian, vulvar, vaginal, and other gynecologic malignancies); or
8. Urine leakage from the vagina (for example, from a genitourinary fistula); or
9. Lower genital tract trauma with suspicion of urinary tract involvement, including urethral stricture; or
10. Urine dribbling post voiding (for example, from a urethral diverticulum); or
11. Injection of therapeutic agents for urinary incontinence; or
12. Verification of suprapubic catheter placement; or
13. Removal of indwelling ureteral stents not amenable to office-based procedure; or
14. Recurrent urinary tract infection (defined as 3 or more urinary tract infections in 12 months) when any of the following risk factors are present:
    1. Prior urinary tract surgery or trauma; or
    2. Gross hematuria after resolution of infection; or
    3. Previous bladder or renal calculi; or
    4. Obstructive symptoms (such as straining, weak stream, intermittency, hesitancy), low uroflowmetry or high post void residual; or
    5. Urea-splitting bacteria on culture (for example, Proteus, Yersinia); or
    6. Bacterial persistence after sensitivity-based therapy; or
    7. Prior abdominopelvic malignancy; or
    8. Diabetes or otherwise immunocompromised; or
    9. Pneumaturia, fecaluria, anaerobic bacteria or a history of diverticulitis; or
    10. Repeated pyelonephritis (fevers, chills, vomiting, costovertebral tenderness); or
    11. Asymptomatic microhematuria after resolution of infection.

Not Medically Necessary:

Outpatient cystourethroscopy is considered not medically necessary for any other indication not listed above as medically necessary.

Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met for outpatient procedures:

CPT

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met.

Discussion/General Information

A cystoscopy is a surgical procedure in which a tube with a small camera on the end (endoscope) is inserted into the bladder to examine the lumen of the bladder, urethra, and the prostate. A related procedure, the urethroscopy, is done to examine the urethral lumen to look for urethral diseases or abnormalities. For the cystoscopy, the endoscope is inserted into the urethra which allows visualization of both the bladder and the urethra, thus the term cystourethroscopy. In addition to the camera, small instruments can also be passed through the endoscope that can be used to treat urinary problems. A diagnostic cystourethroscopy can be done as part of an evaluation of abnormal symptoms or laboratory findings. Cystourethroscopy can be performed with local anesthesia while the member is awake, but it can also be performed during or after pelvic surgery with regional or general anesthesia.

Hematuria can occur with or without other urinary tract symptoms. Without symptoms, hematuria may still be indicative of urinary or bladder problems. A 2012 study by Cha reported on 1182 participants who presented with asymptomatic hematuria. A total of 245 participants were found to have bladder cancer; 138 had low-grade tumors while 97 participants had high-grade tumors. While there are limitations to this study, including a possible increased probability of bladder cancer in the cohort based on local referral patterns, the results indicate that hematuria should not be ignored.

Goldberg and colleagues (2008) reviewed the charts of 1584 participants who had lower urinary tract symptoms and subsequent cystourethroscopy in an attempt to ascertain whether microscopic hematuria was a reliable predictor of cancer risk. Microscopic hematuria was found in 14.8% of the participants, with 1.7% then found to have biopsy-confirmed bladder cancer. Among the participants without hematuria, 0.45% were found to have bladder cancer and 60% of the participants presented with a normal initial dipstick urinalysis. While this study has some limitations including its retrospective design, the findings suggest that cystourethroscopy can be used for the evaluation of lower urinary tract symptoms including hematuria.

In a 2015 study of 109 participants with hematuria, Ahmed and colleagues compared transabdominal ultrasound to cystourethroscopy. All participants had both ultrasound and cystourethroscopy. The authors concluded that while ultrasound can be used as a first-line imaging tool for evaluation of hematuria in settings where cystourethroscopy is not available, it cannot replace cystourethroscopy as the gold standard for evaluation of hematuria.

Whether or not a stone passes spontaneously, stone passage can depend on the size and/or location of the stone. According to a 2016 American Urological Association guideline for the surgical management of stones, ureteroscopy can be used for mid or distal ureteral stones.

In 2019 the American Urological Association/Canadian Urological Association/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction published their guideline regarding recurrent uncomplicated urinary tract infection in women. This guideline refers to “an otherwise healthy adult female with an uncomplicated recurrent urinary tract infection." The authors define a recurrent urinary tract infection as “two separate culture-proven episodes of acute bacterial cystitis and associated symptoms within six months or three episodes within one year.” Upon evaluation, according to expert opinion, for a healthy adult individual with an uncomplicated recurrent urinary tract infection, cystoscopy and upper tract imaging should not be routinely done.

While cystourethroscopy is considered to be the gold standard procedure for many indications and is a low-risk surgical procedure, like all surgical procedures it is not without risk. A 2014 study by Rambachan and colleagues reported on surgical outcomes and the rate of hospital readmissions following urological surgery. In looking at 7795 participants, outpatient urological surgery had a 3.7% readmission rate within 30 days. Cystourethroscopy and resection of bladder tumor was the most common procedure that had been performed. However, it is important to keep in mind that certain gynecologic surgical procedures themselves are considered to be high-risk for complications and the addition of cystourethroscopy may help to avoid additional surgery.

Definitions

Cystourethroscopy: A surgical procedure which combines a cystoscopy and a urethroscopy. It can be done to examine the bladder and urethral lumen to look for urethral diseases or abnormalities.

Gross hematuria: Blood in the urine which is visible to the naked eye.

Hematuria: Blood in the urine.

Microscopic hematuria: Blood in the urine which is only visible by a microscope.

References

Peer Reviewed Publications:

1. Ahmed FO, Hamdan HZ, Abdelgalil HB, Sharfi AA. A comparison between transabdominal ultrasonographic and cystourethroscopy findings in adult Sudanese patients presenting with haematuria. Int Urol Nephrol. 2015; 47(2):223-228.
2. Cha EK, Tirsar LA, Schwentner C, et al. Accurate risk assessment of patients with asymptomatic hematuria for the presence of bladder cancer. World J Urol. 2012; 30(6):847-852.
3. Gilmour DT, Das S, Flowerdew G. Rates of urinary tract injury from gynecologic surgery and the role of intraoperative cystoscopy. Obstet Gynecol. 2006; 107(6):1366-1372.
4. Gleason JL. Cystoscopy and other urogynecologic procedures. Obstet Gynecol Clin North Am. 2013; 40(4):773-785.
5. Goldberg RP, Sherman W, Sand PK. Cystoscopy for lower urinary tract symptoms in urogynecologic practice: the likelihood of finding bladder cancer. Int Urogynecol J Pelvic Floor Dysfunct. 2008; 19(7):991-1004.
6. Rambachan A, Matulewicz RS, Pilecki M, et al. Predictors of readmission following outpatient urological surgery. J Urol. 2014; 192(1):183-188.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Urological Association. Surgical management of stones: American Urological Association/Endourological Society Guideline. 2016. Available at: https://www.auanet.org/guidelines. Accessed on April 10, 2023.
2. American Urological Association (AUA)/Canadian Urological Association (CUA)/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU). Recurrent uncomplicated urinary tract infections in women: AUA/CUA/SUFU guideline. 2019; confirmed 2022. Available at: https://www.auanet.org/guidelines-and-quality/guidelines/recurrent-uti. Accessed on April 11, 2023.
3. Barocas DA, Boorjian SA, Alvarez RD et al. Microhematuria: AUA/SUFU guideline. J Urol. 2020; 204(4):778-786. Available at: https://www.auanet.org/guidelines-and-quality/guidelines/microhematuria. Accessed on April 10, 2023.
4. Grossfeld GD, Wolf JS Jr, Litwan MS, et al. Asymptomatic microscopic hematuria in adults: summary of the AUA best practice policy recommendations. Am Fam Physician. 2001; 63(6):1145-1154.
5. Rodgers M, Nixon J, Hempel S, et al. Diagnostic tests and algorithms used in the investigation of haematuria: systematic reviews and economic evaluation. Health Technol Assess. 2006; 10(18):iii-iv, xi-259.

Websites for Additional Information

1. National Institute of Diabetes and Digestive and Kidney Diseases. Available at: https://www.niddk.nih.gov/health-information/diagnostic-tests/cystoscopy-ureteroscopy. Accessed on April 10, 2023.
   • Cystoscopy and Ureteroscopy

Index

Cystoscopy
Cystourethroscopy
Urethroscopy

History

Status

Federal and State law, as well as contract language, and Medical Policy take precedence over Clinical UM Guidelines. We reserve the right to review and update Clinical UM Guidelines periodically. Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general adoption by plans or lines of business for consistent review of the medical necessity of services related to the clinical guideline when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card.

Alternatively, commercial or FEP plans or lines of business which determine there is not a need to adopt the guideline to review services generally across all providers delivering services to Plan’s or line of business’s members may instead use the clinical guideline for provider education and/or to review the medical necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in some other manner.

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