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

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.