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    v1.0.28
    OpenPayerPolicy UpdatesUrologyAmbetter Nevada Urodynamic Testing Coverage | Open…
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    ModifiedAmbetter NevadaPolicy CP.MP.98

    Urodynamic Testing

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    Defines when urodynamic studies are medically necessary to assist in diagnosing urologic dysfunction and identifies testing that is not medically necessary for providers treating health plan members or enrollees with symptomatic or otherwise qualifying urinary and neurologic conditions.

    Policy Summary
    PayerAmbetter Nevada
    PolicyUrodynamic Testing
    Policy CodePolicy CP.MP.98
    Change TypeModified
    Effective DateN/A
    Last ReviewMar 1, 2023
    Next Review DateN/A
    Key ActionBefore urodynamic testing, document an appropriate history, physical examination, and urinalysis with microscopy.
    SourceLink
    POLICY UPDATE CHANGES

    The March 2023 annual review added prostate nodule, asymmetry, or other suspicion of prostate cancer as a qualifying medical-necessity indication.

    The March 2022 revision changed the indication wording from incontinence associated with recurrent urinary tract infection to urinary incontinence.

    9Qualifying clinical indications
    2Studies permitted per visit before testing is not medically necessary
    8Urodynamic and related procedure codes

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    1
    Screening exception
    3Required initial evaluation components

    Medical Necessity and Exclusions

    Medically Necessary Indications

    Urodynamic testing is medically necessary to assist in the diagnosis of urologic dysfunction when any one of the following indications is present.

    Qualifying indications

    • Uncertain diagnosis: The diagnosis is uncertain and an appropriate initial treatment plan cannot be developed based on the clinical diagnostic evaluation.
    • Failed therapeutic trial: The patient has failed to respond to an adequate therapeutic trial.
    • Surgical consideration: Urologic surgical intervention is being considered, particularly if previous surgery failed or if the patient is a high surgical risk.

    • Qualifying comorbid or associated conditions

      • Urinary incontinence.
      • Difficult bladder emptying: Persistent symptoms of difficult bladder emptying.
      • Prior pelvic surgery: History of previous anti-incontinence surgery or radical pelvic surgery.
      • Pelvic prolapse: Symptomatic pelvic prolapse.
      • Prostate cancer suspicion: Prostate nodule, asymmetry, or other suspicion of prostate cancer.
      • Abnormal residual or urinalysis: Abnormal post-void residual or urinalysis.

    Not Medically Necessary Testing

    The following urodynamic testing is considered not medically necessary.

    Not medically necessary testing

    • More than one cystometrogram per visit: More than one cystometrogram is performed per visit.>1 per visit

      Applies to CPT 51725 or 51726.

    • More than one uroflowmetry study per visit: More than one uroflowmetry study is performed per visit.>1 per visit

      Applies to CPT 51736 or 51741.

    • Asymptomatic screening: Urodynamic testing is used for screening in an asymptomatic patient.

      Exception: evaluation of neurogenic bladder or urologic abnormalities associated with complex anorectal malformation.

    Screening urodynamic testing is excluded for asymptomatic patients. The exception is evaluation of neurogenic bladder or urologic abnormalities associated with complex anorectal malformation.

    No more than one cystometrogram per visit is considered medically necessary. More than one study using CPT 51725 or 51726 per visit is considered not medically necessary. Similarly, no more than one uroflowmetry study per visit using CPT 51736 or 51741 is considered medically necessary.

    Urodynamic testing used for screening asymptomatic patients is considered not medically necessary. The exception is testing performed to evaluate neurogenic bladder or urologic abnormalities associated with complex anorectal malformation.

    Covered Procedure and Diagnosis Codes

    Covered CPT CodesCPTCovered
    51725Simple cystometrogram (CMG) (eg, spinal manometer).
    51726Complex cystometrogram (ie, calibrated electronic equipment).
    51727Complex cystometrogram (ie, calibrated electronic equipment); with urethral pressure profile studies (i.e., urethral closure pressure profile), any technique.
    51728Complex cystometrogram (ie, calibrated electronic equipment); with voiding pressure studies (ie, bladder voiding pressure), any technique.
    51729Complex cystometrogram (ie, calibrated electronic equipment); with voiding pressure studies (ie, bladder voiding pressure) and urethral pressure profile studies (ie, urethral closure pressure profile), any technique.
    51736Simple uroflowmetry (UFR) (eg, stop-watch flow rate, mechanical uroflowmeter).
    51741Complex uroflowmetry (eg, calibrated electronic equipment).
    +51797Voiding pressure studies, intra-abdominal (ie, rectal, gastric, intraperitoneal (List separately in addition to code for primary procedure).
    51798Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging
    Covered ICD-10-CM Diagnosis Codes That Support Medical NecessityICD-10Covered
    A18.13Tuberculosis of other urinary organs.
    C70.1Malignant neoplasm of spinal meninges.
    C72.0Malignant neoplasm of spinal cord.
    C72.1Malignant neoplasm of cauda equina.
    D33.4Benign neoplasm of spinal cord.
    E10.69Type 1 diabetes mellitus with other specified complications.
    E11.69Type 2 diabetes mellitus with other specified complication.
    G20Parkinson's disease.
    G35Multiple sclerosis.
    G37.3Acute transverse myelitis in demyelinating disease of central nervous system.
    1–10 of 34
    1/4
    Covered ICD-10-CM Diagnosis Codes That Support Medical Necessity for CPT Code 51798ICD-10Covered
    N13.8Other obstructive and reflux uropathy.
    R33.0 through R33.9Retention of urine.
    R35.0Frequency of micturition.

    Documentation and Coverage Guidance

    Note

    Review Medicare Coverage Guidance

    For Medicare members/enrollees, review all applicable Medicare National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Medicare Coverage Articles before applying this policy’s criteria. Refer to the CMS website for current Medicare guidance.

    Documentation Required

    Complete Initial Evaluation and Manage Infection

    Before ordering urodynamic testing, complete an initial evaluation that includes an appropriate history, physical examination, and urinalysis with microscopy. If infection is present, treat it and observe treatment effectiveness before performing urodynamic testing or initiating other therapeutic interventions.

    Documentation Required

    Document Clinical Rationale for Testing

    Clinical Background

    Urodynamic testing evaluates the relationship between bladder and abdominal pressures during bladder filling, storage, and emptying. Common studies include cystometrogram, uroflowmetry, urethral pressure profile, and voiding pressure studies; together, they help characterize abnormal voiding patterns in symptomatic patients.

    Urodynamic Testing Terms

    Simple cystometrogram
    ProcedureSimple cystometrogram (CPT 51725)
    CatheterizationA pressure catheter is inserted into the bladder.
    MeasurementA manometer records pressure and flow in the lower urinary tract.
    Complex cystometrogram
    ProcedureComplex cystometrogram (CPT 51726)
    Bladder fillingThe bladder is filled with water or gas through a transurethral catheter.
    Pressure measurementsRectal pressure is obtained while a transducer measures intravesical pressure.
    Policy Summary
    PayerAmbetter Nevada
    PolicyUrodynamic Testing
    Policy CodePolicy CP.MP.98
    Change TypeModified
    Effective DateN/A
    Last ReviewMar 1, 2023
    Next Review DateN/A
    Key ActionBefore urodynamic testing, document an appropriate history, physical examination, and urinalysis with microscopy.
    SourceLink
    On This Page
    Medical Necessity and ExclusionsCovered Procedure and Diagnosis CodesDocumentation and Coverage GuidanceClinical BackgroundUrodynamic Testing Terms
  1. Diabetes with secondary incontinence: Diabetes mellitus with secondary urinary incontinence.
  2. Neurologic voiding condition: A neurological condition affecting voiding function, including neurogenic bladder associated with multiple sclerosis, Parkinson's disease, or spinal cord lesions or injury.
  3. Complex anorectal malformation.

    4. Document the patient’s symptoms, clinical diagnostic evaluation, qualifying indication, and why urodynamic results are needed to guide diagnosis or treatment. Testing is medically necessary when it assists diagnosis of urologic dysfunction, such as when the diagnosis is uncertain and an initial treatment plan cannot be developed, an adequate therapeutic trial has failed, surgical intervention is being considered, or a qualifying comorbid condition is present.

    • Qualifying conditions may include urinary incontinence; persistent difficult bladder emptying; prior anti-incontinence or radical pelvic surgery; symptomatic pelvic prolapse; prostate findings or other suspicion of prostate cancer; abnormal post-void residual or urinalysis; diabetes with secondary urinary incontinence; neurologic conditions affecting voiding; or complex anorectal malformation.
    Denial Risk

    Avoid Duplicate Testing in One Visit

    Do not report more than one applicable cystometrogram or uroflowmetry study per visit; additional testing beyond these limits is considered not medically necessary.

    • Cystometrogram: CPT 51725 or 51726.
    • Uroflowmetry: CPT 51736 or 51741.
    Denial Risk

    Do Not Perform Asymptomatic Screening

    Urodynamic testing for screening in asymptomatic patients is not medically necessary, except when evaluating neurogenic bladder or urologic abnormalities associated with complex anorectal malformation.

    • Document symptoms or the applicable exception when testing an asymptomatic patient.
    Related assessmentsComplex cystometrograms may be performed with urethral pressure studies or voiding pressure studies.
    Uroflowmetry
    DefinitionUroflowmetry measures and records the volume of urine flow over time.
    Simple uroflowmetrySimple uroflowmetry (CPT 51736) uses a stopwatch to record urine-flow volume over time.
    Complex uroflowmetryComplex uroflowmetry (CPT 51741) uses electronic equipment to measure and record urine-flow volume over time.
    Post-void residual
    DefinitionPost-void residual measurement assesses residual urine and/or bladder-emptying capacity.
    TimingThe measurement is performed after voiding.
    MethodUltrasound is used to measure the residual urine or bladder-emptying capacity (CPT 51798).
    Voiding pressure study
    DefinitionA voiding pressure study measures the effort the patient makes while voiding.
    PressureThe measurement includes the pressure required for voiding.
    Urine flowThe study also measures the subsequent urine flow.