Anthem Blue Cross ConnecticutCommercial Clinical Policy

Anthem Blue Cross Connecticut CG-SURG-51 Outpatient Cystourethroscopy Form


Outpatient Cystourethroscopy

Indications

(748966) Does the patient have gross hematuria without evidence of glomerular disease or infection? 
(748967) Does the patient have gross hematuria with blood clots? 
(748968) Does the patient have microscopic hematuria without evidence of glomerular disease, infection, or known cause of hematuria and there is an increased risk for malignancy? 
(748969) Is the cystourethroscopy for management of kidney stones unlikely to pass spontaneously? 
(748970) Is the procedure for suspected urinary tract injury or foreign body, such as ureteral injury, bladder incision, or vesical mesh or suture erosion? 

YesNoN/A
YesNoN/A
YesNoN/A

Sign up to see the rest of the questions

Unlock the remaining questions and the full coverage workflow.

Sign up for free
Effective Date

09/27/2023

Last Reviewed

05/11/2023

Original Document

  Reference



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.