CurrentBlue Cross Blue Shield - MassachusettsPolicy 471
Injectable bulking agents for urinary and fecal incontinence
Defines medical necessity and investigational coverage policy for periurethral (urinary) and perianal (fecal) injectable bulking agents, applicable to Commercial members (HMO, POS, PPO, Indemnity). Lists required CPT/HCPCS/ICD-10 codes, prior authorization rules for inpatient services, and summarizes evidence and approved/ investigational agents.
Policy Summary
PayerBlue Cross Blue Shield - Massachusetts
PolicyInjectable bulking agents for urinary and fecal incontinence
Policy CodePolicy 471
Change TypeClarified (12/2024); Revised expansion (3/2022)
Effective Date
Next Review Date
Key ActionPrecertification/preauthorization is required for inpatient procedures; submit the listed ICD-10 diagnosis codes with CPT/HCPCS and meet medical necessity criteria.
POLICY UPDATE CHANGES
12/2024 annual policy review: References updated; policy statements unchanged.
3/2022 expansion: Medically necessary policy statement in men and women with stress urinary incontinence who have failed appropriate conservative therapy expanded.
8/2015 Contigen removed from medically necessary statement as it is no longer available; clarified coding information effective 8/1/2015.
1FDA-approved urinary bulking agent classes listed as medically necessary
1FDA-approved product for fecal incontinence discussed (NASHA Dx / Solesta)
4Examples of urinary bulking agents named