Anthem Blue Cross Connecticut CG-SURG-51 Outpatient Cystourethroscopy Form
This procedure is not covered
This document addresses cystourethroscopy in the outpatient setting.
Clinical Indications
Medically Necessary:
Outpatient cystourethroscopy is considered medically necessary for any of the following indications:
- Gross hematuria without evidence of glomerular disease or infection; or
- Gross hematuria with blood clots; or
- Microscopic hematuria without evidence of glomerular disease, infection, or known cause of hematuria and there is an increased risk for malignancy; or
- Management of kidney stones unlikely to pass spontaneously; or
- 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
- Urinary urgency, urinary frequency, or urgency incontinence when there is no urinary tract infection (this also includes stress urinary incontinence); or
- 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
- Urine leakage from the vagina (for example, from a genitourinary fistula); 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
- Verification of suprapubic catheter placement; or
- Removal of indwelling ureteral stents not amenable to office-based procedure; or
- Recurrent urinary tract infection (defined as 3 or more urinary tract infections in 12 months) when any of the following risk factors are present:
- Prior urinary tract surgery or trauma; or
- Gross hematuria after resolution of infection; or
- Previous bladder or renal calculi; or
- Obstructive symptoms (such as straining, weak stream, intermittency, hesitancy), low uroflowmetry or high post void residual; or
- Urea-splitting bacteria on culture (for example, Proteus, Yersinia); or
- Bacterial persistence after sensitivity-based therapy; or
- Prior abdominopelvic malignancy; or
- Diabetes or otherwise immunocompromised; or
- Pneumaturia, fecaluria, anaerobic bacteria or a history of diverticulitis; or
- Repeated pyelonephritis (fevers, chills, vomiting, costovertebral tenderness); or
- 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.
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