ModifiedAmbetter NevadaPolicy CP.MP.98

Urodynamic Testing

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Defines medical necessity criteria, coding, and supporting diagnoses for urodynamic studies used in the evaluation of voiding dysfunction for Ambetter Nevada members/enrollees.

Policy Summary

PayerAmbetter Nevada

PolicyUrodynamic Testing

Policy CodePolicy CP.MP.98

Change TypeCoding and diagnosis list updatesCPT addition

Effective Date

Next Review Date

Key ActionWhen billing listed CPT procedures, include an ICD-10 diagnosis that supports medical necessity per the policy criteria.

SourceLink

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ModifiedAmbetter NevadaPolicy CP.MP.98

Urodynamic Testing

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Sign up for Ambetter Nevada Policy CP.MP.98 alerts

Get alerted when Policy CP.MP.98 changes without checking for updates manually.

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Defines medical necessity criteria, coding, and supporting diagnoses for urodynamic studies used in the evaluation of voiding dysfunction for Ambetter Nevada members/enrollees.

Policy Summary

PayerAmbetter Nevada

PolicyUrodynamic Testing

Policy CodePolicy CP.MP.98

Change TypeCoding and diagnosis list updatesCPT addition

Effective Date

Next Review Date

Key ActionWhen billing listed CPT procedures, include an ICD-10 diagnosis that supports medical necessity per the policy criteria.

SourceLink

POLICY UPDATE CHANGES

Code update: ICD-10 N40.1 and R35.1 no longer specific to 51798 and moved to list of codes that support medical necessity.

Added multiple ICD-10 codes that support medical necessity (examples listed include A18.13, G82.21, G82.22, R39.11, and ranges S14.0XXA–S14.9XXS and S24.0XXA–S24.9XXS).

Added CPT 51792 to CPT coding table.

51792CPT codes updated — new code added

>1 per visitNot medically necessary: more than one cystometrogram or uroflowmetry per visit

multiple addedICD-10 codes supporting medical necessity updated/expanded

10+ codesprocedure CPT codes referenced

Coverage / Medical Necessity Criteria

Not medically necessary

Not medically necessary in specified situations:

Not medically necessary: A. More than one cystometrogram (CPT codes 51725 or 51726) or uroflowmetry study (CPT codes 51736 or 51741) per visit. B. The use of any urodynamic testing for screening in asymptomatic patients, except for evaluation of neurogenic bladder or urological abnormalities associated with complex anorectal malformation.

Policy II.A-B

Screening of asymptomatic patients with urodynamic testing is considered not medically necessary, with two narrow exceptions. The policy specifically allows testing when performed to evaluate neurogenic bladder or for urologic abnormalities associated with complex anorectal malformation. Providers should not use urodynamic studies for routine screening in patients without symptoms unless one of these exceptions applies.

Performing more than one cystometrogram (CPT 51725 or 51726) or more than one uroflowmetry study (CPT 51736 or 51741) per visit is considered not medically necessary and may be denied. Submit only a single CMG or single uroflowmetry per patient visit unless an exceptional, documented clinical rationale consistent with policy indications is present.

This clinical policy is intended as a guide to medical necessity to assist in coverage decision-making and administration of benefits. It does not constitute a contract or guarantee of payment. Coverage remains subject to the terms, conditions, exclusions and limitations of the member's benefit documents and to applicable state and federal requirements; where state Medicaid provisions conflict with this policy, state Medicaid rules take precedence.

No additional explicit not medically necessary conditions are specified in the referenced portions of the document beyond those listed in policy Section II. Providers must follow the criteria and exclusions detailed elsewhere in this policy and in the member's applicable coverage documents when determining medical necessity.

Procedure and Diagnosis Codes

Covered CPT CodesCPTCovered

51725	Simple cystometrogram (CMG) (eg, spinal manometer).
51726	Complex cystometrogram (ie, calibrated electronic equipment).
51727	Complex CMG; with urethral pressure profile studies.
51728	Complex CMG; with voiding pressure studies.
51729	Complex CMG; with voiding pressure studies and urethral pressure profile studies.
51736	Simple uroflowmetry (eg, stop-watch flow rate, mechanical uroflowmeter).
51741	Complex uroflowmetry (eg, calibrated electronic equipment).
51792	Stimulus evoked response (eg, measurement of bulbocavernous reflex latency time).
51797	Voiding pressure studies, intra-abdominal (ie, rectal, gastric, intraperitoneal).
51798	Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging.

CPT codes (examples noted in revision log)CPTCovered

51792

CPT code added to CPT coding table

Supporting ICD-10 Codes (sample from policy list)ICD-10

A18.13	Tuberculosis of other urinary organs.
A52.10	Symptomatic neurosyphilis, unspecified.
C61	Malignant neoplasm of prostate.
D29.1	Benign neoplasm of prostate.
E10.21	Type 1 diabetes mellitus with diabetic nephropathy.
G35	Multiple sclerosis.
N30.10	Interstitial cystitis (chronic) without hematuria.
N31.0	Neuromuscular dysfunction of bladder, not elsewhere classified.
N40.1	Benign prostatic hyperplasia with lower urinary tract symptoms.
N81.0	Female genital prolapse.

1–10 of 12

1/2

ICD-10 codes supporting medical necessity (examples and ranges)ICD-10Covered

N40.1	ICD-10 code moved to list that supports medical necessity
R35.1	ICD-10 code moved to list that supports medical necessity
A18.13	ICD-10 code added to list supporting medical necessity
G82.21	ICD-10 code added to list supporting medical necessity
G82.22	ICD-10 code added to list supporting medical necessity
R39.11	ICD-10 code added to list supporting medical necessity
S14.0XXA-S14.9XXS	ICD-10 code range added
S24.0XXA-S24.9XXS	ICD-10 code range added

Additional ICD-10 codes listed in revision logICD-10Covered

G20.A2	ICD-10 code listed in revisions
G20.B1	ICD-10 code listed in revisions
N13.0	ICD-10 code listed in revisions
N35.010	ICD-10 code listed in revisions
R39.12	ICD-10 code listed in revisions

Provider Requirements, Billing & Prior Authorization

Prior Authorization

Procedure codes require supporting diagnosis

Coverage may be provided for the listed CPT procedures when billed with an ICD-10 diagnosis that supports medical necessity per the policy criteria; providers should include a supporting diagnosis on claims that demonstrates one of the policy’s indications (e.g., uncertain diagnosis, failure of therapy, consideration of surgery, comorbid conditions such as urinary incontinence or neurogenic bladder).

Referenced CPT procedures: 51725, 51726, 51727, 51728, 51729, 51736, 51741, 51792, 51797, 51798.
Supporting ICD-10 diagnosis must align with the policy’s medically necessary indications (see policy I.A–D and listed diagnoses).

Prior Authorization

Review NCD/LCD and state Medicaid rules before applying policy

Prior to applying this policy, review applicable Medicare NCDs/LCDs and state Medicaid coverage provisions because those determinations take precedence and may impose additional prior authorization or coverage rules.

State Medicaid provisions take precedence for Medicaid members; refer to the state Medicaid manual.

Definitions and Test Descriptions

inv-21: Simple cystometrogram (CPT 51725) — key/value description

CodeCPT 51725

DefinitionSimple cystometrogram: insertion of a pressure catheter into the bladder and using a manometer to record pressure and flow in the lower urinary tract.

Typical useDistinguish bladder outlet obstruction from other voiding dysfunctions; part of urodynamic evaluation when noninvasive testing is inadequate.

NotesRequires urethral catheterization and carries risks including infection, urethral trauma, and pain; consider conservative evaluation first.

inv-22: Complex cystometrogram (CPT 51726) — key/value description

CodeCPT 51726

Clinical Background

Lower urinary tract symptoms (LUTS) — including urgency, frequency, nocturia and incontinence — commonly overlap and can reflect multiple underlying disorders. Urodynamic studies (for example, cystometrograms and uroflowmetry) are diagnostic tests that evaluate bladder and urethral function by measuring pressures and flow during filling and voiding. Because many urodynamic procedures require urethral catheterization and carry risks related to instrumentation, testing is indicated after an initial clinical evaluation and when results are expected to change management.

Policy Summary

PayerAmbetter Nevada

PolicyUrodynamic Testing

Policy CodePolicy CP.MP.98

Change TypeCoding and diagnosis list updatesCPT addition

Effective Date

Next Review Date

Key ActionWhen billing listed CPT procedures, include an ICD-10 diagnosis that supports medical necessity per the policy criteria.

SourceLink

On This Page

Review Medicare NCDs, LCDs, and Coverage Articles on CMS website for Medicare members/enrollees.

Step Therapy

Conservative therapy before invasive testing

Conservative or empiric non‑invasive treatments (behavioral therapy, pelvic muscle exercises, and pharmacotherapy) are generally acceptable and may be instituted before invasive urodynamic testing when clinically appropriate.

Examples: pelvic muscle (Kegel) exercises, bladder training, biofeedback, anticholinergic or other pharmacotherapies.
Urodynamic testing is indicated only after initial evaluation and when results will inform management.

Documentation Required

Required prior evaluation

An initial evaluation must include at minimum an appropriate history, physical examination, and urinalysis with microscopy; if infection is present it should be treated and the response observed before performing urodynamic testing.

Document history and physical exam findings that justify proceeding to urodynamic testing.
Document urinalysis with microscopy results and any treatment for infection and subsequent response.

Denial Risk

Multiple same-visit studies

Performing more than one cystometrogram (CPT 51725 or 51726) or more than one uroflowmetry study (CPT 51736 or 51741) during the same visit is considered not medically necessary and may be denied.

Do not bill multiple CMG (51725/51726) or multiple uroflowmetry (51736/51741) procedures for a single visit unless clearly documented and justified per policy.
Claims with multiple same‑visit studies are at risk for denial under the policy’s not medically necessary rule.

Documentation Required

Administrative compliance reminder

Providers must follow the coverage documents and applicable administrative policies; this clinical policy is a guide to medical necessity and does not guarantee payment—administrative rules and plan terms apply to claims processing.

Adhere to Health Plan terms, conditions, exclusions, and limitations when submitting claims.
Policy language does not supersede legal, regulatory, or plan‑level administrative requirements.

Note

Coverage administration reminder

Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents and to state and federal requirements; when conflicts exist, legal/regulatory requirements govern.

This policy is a guide and not a contract or guarantee of payment.
If state Medicaid coverage conflicts with this clinical policy, state Medicaid provisions take precedence.

Documentation Required

Provider compliance and documentation reminder

Providers must follow coverage documents and administrative policies and reference the policy’s criteria when planning testing or submitting claims; retain documentation showing the clinical indication and prior evaluations that support medical necessity.

Keep documentation of indications per policy I.A–D, initial evaluation elements (history, physical, urinalysis), and any conservative treatment trials.
Reference code lists and diagnosis mappings when billing to ensure claim alignment with policy criteria.

DefinitionComplex cystometrogram: transurethral bladder filling (water or gas) with simultaneous rectal pressure measurement and a transducer to measure intravesical pressure using calibrated electronic equipment.

Typical useUsed when more detailed measurement of bladder and abdominal pressures is needed; may be reported with additional urethral pressure or voiding pressure studies (51727-51729).

NotesPart of urodynamic testing that requires urethral instrumentation and carries risks; perform after initial evaluation when results will change management.

inv-23: Uroflowmetry (CPT 51736, 51741) — key/value description

CodesCPT 51736 (simple), CPT 51741 (complex)

DefinitionUroflowmetry: measurement of urine flow over time. Simple uses a stopwatch to record volume over time; complex uses calibrated electronic equipment to measure and record flow.

Typical useNoninvasive assessment of urine flow rate and pattern; may be appropriate before invasive urodynamic testing depending on clinical scenario.

NotesOften used with post-void residual measurement (e.g., CPT 51798) as part of initial noninvasive evaluation; does not require intravesical pressure measurement.

inv-24: Urodynamic studies — general description and referenced guidelines

ScopeUrodynamic studies: diagnostic tests that evaluate bladder and urethral function including cystometry, pressure flow studies, urethral function testing, voiding pressure studies, and uroflowmetry.

Guideline referencesReferenced guidelines include AUA/SUFU guideline (Winters et al., J Urol. 2012) and multiple AUA literature updates and systematic reviews listed in references.

Risks and considerationsMany urodynamic tests require urethral catheterization and carry risks (infection, urethral trauma, pain); perform when results will influence management and after initial evaluation.

Related proceduresIncludes associated CPTs such as 51725-51729 (cystometrogram variants), 51736/51741 (uroflowmetry), 51797 (voiding pressure studies), and 51798 (post-void residual by ultrasound).