CurrentArizona Complete HealthPolicy CP.MP.98

Clinical Policy: Urodynamic Testing

Defines medical necessity criteria, coding, and indications for urodynamic studies used in the evaluation of voiding dysfunction for members/enrollees of Centene-affiliated health plans (Arizona Complete Health).

Policy Summary

PayerArizona Complete Health

PolicyUrodynamic Testing (Clinical Policy)

Policy CodePolicy CP.MP.98

Change TypeCoding and criteria updates (CPT 51792 addedICD-10 tables revised)

Effective Date

Next Review Date

Key ActionDocument diagnosis codes that support medical necessity when billing listed CPT codes; ensure pre-test evaluation (history, physical, urinalysis) is completed and infection treated before testing.

SourceLink

POLICY UPDATE CHANGES

Added CPT 51792 to CPT coding table.

Moved ICD-10 N40.3 from ICD-10 Table 2 to ICD-10 Table 1 and added multiple ICD-10 codes to the list that support medical necessity.

Updated I.D.6 language to 'Abnormal post void residual urine volume.'

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

manyICD-10 codes listed

9+CPT procedure codes

1CPT added

multiple

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Coverage and Medical Necessity Criteria

Not Medically Necessary

The following are considered not medically necessary:

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

These are explicit not medically necessary rules and may result in denial.

Referenced criteria (partial)

Policy contains multiple medical necessity criteria sections (e.g., I.D.1, I.D.5, I.D.6) and refers to ICD-10 tables supporting medical necessity.

I.D.6: Abnormal post void residual urine volume

Wording updated in most recent annual review and listed as a criterion for testing

I.D.5: Prostate nodule, asymmetry or other suspicion of prostate cancer

Added as a distinct criterion in prior revisions

The use of urodynamic testing for screening asymptomatic patients is considered not medically necessary except in two specified situations: evaluation of neurogenic bladder and assessment of urological abnormalities associated with complex anorectal malformation. This exclusion applies to routine screening of asymptomatic individuals and aligns with the policy's intent to reserve invasive diagnostic testing for patients with symptoms or specific clinical indications.

There are no additional explicit clinical exclusions listed in these sections. Coverage and claim determinations remain subject to the member's benefit terms, plan-level administrative policies, and the Important Reminder that this policy is a guide to medical necessity and does not replace the coverage documents or applicable state and federal requirements.

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

This portion of the document does not list additional specific ‘not medically necessary’ conditions beyond those already stated; adjudication of claims and denials for services will be governed by medical necessity determinations, benefit limitations, and applicable plan policies as described in the Important Reminder.

Procedure and Diagnosis Coding

Procedure CPT CodesCPT

51725	Simple cystometrogram (CMG) (eg, spinal manometer).
51726	Complex cystometrogram (ie, calibrated electronic equipment).
51727	Complex cystometrogram (ie, calibrated electronic equipment); with urethral pressure profile studies.
51728	Complex cystometrogram (ie, calibrated electronic equipment); with voiding pressure studies.
51729	Complex cystometrogram (ie, calibrated electronic equipment); with voiding pressure studies and urethral pressure profile studies.
51736	Simple uroflowmetry (UFR) (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.

ICD-10 Diagnosis Codes Supporting Medical NecessityICD-10

A18.13	Tuberculosis of other urinary organs.
A52.10	Symptomatic neurosyphilis, unspecified.
A52.11	Tabes dorsalis.
A52.12	Other cerebrospinal syphilis.
A52.13	Late syphilitic meningitis.
A52.14	Late syphilitic encephalitis.
A52.15	Late syphilitic neuropathy.
A52.16	Charcot's arthropathy (tabetic).
A52.17	General paresis.
A52.19	Other symptomatic neurosyphilis.

1–10 of 91

1/10

CPT codes (added)CPTCovered

51792

CPT code added to CPT coding table

ICD-10 codes (examples added/moved)ICD-10Covered

N40.1	ICD-10 code listed as supporting medical necessity
R35.1	ICD-10 code listed as supporting medical necessity
N40.3	ICD-10 code moved from Table 2 to Table 1
A18.13	ICD-10 code listed as supporting medical necessity
G82.21	ICD-10 code listed as supporting medical necessity
G82.22	ICD-10 code listed as supporting medical necessity
R39.11	ICD-10 code listed as supporting medical necessity
S14.0XXA	ICD-10 code listed as supporting medical necessity
S14.9XXS	ICD-10 code listed as supporting medical necessity
S24.0XXA	ICD-10 code listed as supporting medical necessity

1–10 of 11

1/2

ICD-10 codes (additional examples)ICD-10Covered

A52.10	ICD-10 code listed as supporting medical necessity
C61	ICD-10 code listed as supporting medical necessity
G20.A1	ICD-10 code listed as supporting medical necessity
G20.A2	ICD-10 code listed as supporting medical necessity
N13.0	ICD-10 code listed as supporting medical necessity
N35.010	ICD-10 code listed as supporting medical necessity
N36.0	ICD-10 code listed as supporting medical necessity
R39.12	ICD-10 code listed as supporting medical necessity
T79.5XXA	ICD-10 code listed as supporting medical necessity

inv-13: Maximum procedures per visit

Policy limitNo more than one cystometrogram (CPT 51725 or 51726) or one uroflowmetry (CPT 51736 or 51741) may be performed per visit.

ConsequencePerforming more than one of these procedures per visit is considered not medically necessary and may be denied.

Relevant CPTs51725, 51726, 51736, 51741.

inv-14: Post void residual

Updated criterion wordingAbnormal post void residual urine volume.

Context

Provider Requirements, Documentation, and Billing Guidance

Billing Rule

Procedure codes require supporting diagnosis

Procedure codes listed in the policy must be billed with diagnosis code(s) that support medical necessity. Coverage may be provided only when CPT codes are accompanied by an appropriate supporting ICD-10-CM diagnosis that justifies the urodynamic testing.

Affected CPT codes require a supporting diagnosis on the claim.
See coding table and ICD-10 list in the policy for diagnoses that support medical necessity.

Denial Risk

Screening in asymptomatic patients

Urodynamic testing is not appropriate as a screening tool in asymptomatic patients. Testing for screening purposes is considered not medically necessary except when evaluating neurogenic bladder or urologic abnormalities associated with complex anorectal malformation.

Clinical Background and Guideline References

Lower urinary tract symptoms (LUTS) and urinary incontinence are common clinical problems with overlapping presentations. Urodynamic studies (including cystometrograms, uroflowmetry, urethral pressure profiles and voiding pressure studies) are diagnostic procedures that measure bladder and abdominal pressures during filling and voiding to help distinguish causes such as bladder outlet obstruction versus other dysfunction. Because many urodynamic tests are invasive and carry risks (for example, infection, trauma, and pain), testing is intended to supplement an initial clinical evaluation and is performed when additional diagnostic information will affect management decisions.

Definitions of Procedures and Terms

inv-25: Simple cystometrogram

DefinitionSimple cystometrogram: physician inserts a pressure catheter into the bladder and records pressure and flow in the lower urinary tract using a manometer.

CPT code51725 — Simple cystometrogram (CMG) (eg, spinal manometer).

Clinical useUsed to distinguish bladder outlet obstruction from other voiding dysfunctions.

inv-26: Complex cystometrogram

DefinitionComplex cystometrogram: transurethral catheter fills the bladder while rectal pressure is obtained and intravesical pressure is measured with calibrated electronic equipment.

VariantsMay be reported with urethral pressure profile (51727), with voiding pressure studies (51728), or both (51729).

Policy Changes and Revision History

03/25/24coding_additionLatest

CPT 51792 was added to the CPT coding table.

03/24/23criteria_clarification

I.D.6 language updated to 'Abnormal post void residual urine volume.'

03/22/23icd10_table_update

ICD-10 code N40.3 was moved from ICD-10 Table 2 to ICD-10 Table 1 and multiple ICD-10 codes were added to lists supporting medical necessity.

Policy Summary

PayerArizona Complete Health

PolicyUrodynamic Testing (Clinical Policy)

Policy CodePolicy CP.MP.98

Change TypeCoding and criteria updates (CPT 51792 addedICD-10 tables revised)

Effective Date

Next Review Date

SourceLink

On This Page

Listed as one of the indications under section I.D (criterion for urodynamic testing).

Related CPTMeasurement of post-void residual by ultrasound (CPT 51798) may be used to assess PVR.

Use of urodynamic testing for asymptomatic screening is not medically necessary, except as specified (neurogenic bladder, complex anorectal malformation).

Note

State/Medicare conformity note

When state Medicaid provisions or Medicare NCDs/LCDs conflict with this clinical policy, the state Medicaid or Medicare provisions take precedence. Providers should review applicable state Medicaid manuals and Medicare coverage determinations prior to applying this policy.

For Medicaid members/enrollees, state Medicaid coverage provisions override this clinical policy where conflicts exist.
For Medicare members/enrollees, review applicable NCDs, LCDs, and Medicare Coverage Articles (CMS website) for consistency before applying this policy.

Prior Authorization

Pre-test evaluation required

An initial clinical evaluation is required before performing invasive urodynamic testing. At minimum, this pre-test evaluation must include an appropriate history, physical examination, and urinalysis with microscopy; treat any infection and confirm effectiveness of treatment prior to urodynamic testing.

Minimum pre-test evaluation: history, physical exam, and urinalysis with microscopy.
If infection is present, it should be treated and response observed before invasive testing.

Step Therapy

No explicit step therapy requirements

This policy does not specify any explicit step therapy requirements for urodynamic testing. Conservative or empiric non-invasive treatments (e.g., pelvic muscle exercises, behavioral therapies, pharmacotherapy) may be instituted without urodynamic testing, but no formal step therapy sequence is mandated by this policy.

No explicit step therapy requirements are specified in this policy.
Conservative/non-invasive treatments may be tried per clinical judgment prior to invasive testing, but this is not framed as a required step-therapy protocol.

CPT reference51726 — Complex cystometrogram (calibrated electronic equipment).

inv-27: Simple uroflowmetry

DefinitionSimple uroflowmetry: a stopwatch is used to record urine volume over time (manual measurement).

CPT code51736 — Simple uroflowmetry (eg, stop-watch flow rate, mechanical uroflowmeter).

RoleNoninvasive assessment of urinary flow rate to assist in evaluation of voiding dysfunction.

inv-28: Complex uroflowmetry

DefinitionComplex uroflowmetry: electronic equipment is used to measure and record urine flow volume over time.

CPT code51741 — Complex uroflowmetry (eg, calibrated electronic equipment).

ComparisonProvides more precise, electronically recorded flow data compared with simple (stopwatch) uroflowmetry.

inv-29: Voiding pressure studies

DefinitionVoiding pressure studies: measure the effort and pressure the patient generates while voiding, including pressure required and subsequent urine flow.

CPT code51797 — Voiding pressure studies, intra-abdominal (eg, rectal, gastric, intraperitoneal).

UseTypically performed as part of evaluation of bladder outlet obstruction and voiding dysfunction.

inv-30: Post-void residual measurement

DefinitionPost-void residual measurement: measurement of residual urine and/or bladder capacity using ultrasound after voiding (non-imaging).

CPT code51798 — Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging.

RoleNoninvasive test to quantify residual urine and inform need for further urodynamic evaluation.

inv-31: Urodynamic studies

DefinitionUrodynamic studies: diagnostic procedures to assess bladder function, including cystometry, pressure flow studies, urethral function testing, and related measures as described by AUA/SUFU guidelines.

Guideline referenceAUA/SUFU guideline: Winters JC et al., Urodynamic studies in adults: AUA/SUFU guideline (J Urol. 2012).

ScopeUsed to differentiate causes of lower urinary tract symptoms and guide management; many tests are invasive and carry risks (infection, trauma, pain).

10/20icd10_code_relationship_update

ICD-10 N40.1 and R35.1 were removed as codes specific to CPT 51798 and moved to the broader list of codes that support medical necessity; additional ICD-10 codes (A18.13, G82.21, G82.22, R39.11, S14.0XXA–S14.9XXS, S24.0XXA–S24.9XXS) were added.