ModifiedCommunity Care Independent Practice AssociationPolicy CP.MP.98

Urodynamic Testing

Customize your policy alerts

Sign up for communitycareindependentpracticeassociation Policy CP.MP.98 alerts

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

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Defines medical necessity criteria and coding support for commonly used urodynamic studies used to evaluate urologic dysfunction.

Policy Summary

PayerCommunity Care Independent Practice Association

PolicyUrodynamic Testing

Policy CodePolicy CP.MP.98

Change TypeModified

Effective DateN/A

Next Review DateN/A

Key ActionDocument an initial evaluation with an appropriate history, physical examination, and urinalysis with microscopy before urodynamic testing.

SourceLink

POLICY UPDATE CHANGES

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

9CPT procedure codes listed

4Primary medical necessity indication categories

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.

ModifiedCommunity Care Independent Practice AssociationPolicy CP.MP.98

Urodynamic Testing

Customize your policy alerts

Sign up for communitycareindependentpracticeassociation Policy CP.MP.98 alerts

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

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Defines medical necessity criteria and coding support for commonly used urodynamic studies used to evaluate urologic dysfunction.

Policy Summary

PayerCommunity Care Independent Practice Association

PolicyUrodynamic Testing

Policy CodePolicy CP.MP.98

Change TypeModified

Effective DateN/A

Next Review DateN/A

Key ActionDocument an initial evaluation with an appropriate history, physical examination, and urinalysis with microscopy before urodynamic testing.

SourceLink

POLICY UPDATE CHANGES

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

9CPT procedure codes listed

4Primary medical necessity indication categories

Associated conditions

2Not-medically-necessary restrictions

2Screening exceptions

Medical Necessity and Coverage Criteria

Medically Necessary Indications

Urodynamic testing is medically necessary to assist in the diagnosis of urologic dysfunction when at least one of the following indication categories applies:

Qualifying indications

Uncertain diagnosis: The diagnosis is uncertain and an appropriate initial treatment plan cannot be developed based on the clinical diagnostic evaluation.
Failure of therapeutic trial: The patient failed to respond to an adequate therapeutic trial.
Surgical consideration: Urologic surgical intervention is being considered, particularly if previous surgery failed or the patient is at high surgical risk.
Associated comorbid or clinical conditions
- Urinary incontinence is present.
- Difficult bladder emptying: Persistent symptoms of difficult bladder emptying are present.
- Prior pelvic surgery: There is a history of previous anti-incontinence surgery or radical pelvic surgery.
- Pelvic prolapse: Symptomatic pelvic prolapse is present.
- Prostate concern: There is a prostate nodule, asymmetry, or other suspicion of prostate cancer.
- Abnormal residual or urinalysis:

Not Medically Necessary

The following uses of urodynamic testing are considered not medically necessary:

Not medically necessary uses

Multiple same-type studies per visit: More than one cystometrogram (CPT 51725 or 51726) or uroflowmetry study (CPT 51736 or 51741) is performed during the same visit.
Asymptomatic screening: Urodynamic testing is used to screen an asymptomatic patient.
Exception: evaluation of neurogenic bladder or urologic abnormalities associated with complex anorectal malformation is appropriate.

More than one cystometrogram or uroflowmetry study per visit is considered not medically necessary.

Urodynamic testing used to screen asymptomatic patients is not medically necessary. Exceptions apply when testing evaluates neurogenic bladder or urologic abnormalities associated with complex anorectal malformation.

More than one cystometrogram per visit, including CPT 51725 or 51726, or more than one uroflowmetry study per visit, including CPT 51736 or 51741, is considered not medically necessary.

Any urodynamic testing performed for screening in asymptomatic patients is considered not medically necessary, except when evaluating neurogenic bladder or urological abnormalities associated with complex anorectal malformation.

CPT and Diagnosis Coding

CPT CodesCPTCovered

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 (i.e., urethral closure pressure profile), any technique.
51728	Complex cystometrogram (ie, calibrated electronic equipment); with voiding pressure studies (ie, bladder voiding pressure), any technique.
51729	Complex 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.
51736	Simple uroflowmetry (UFR) (eg, stop-watch flow rate, mechanical uroflowmeter).
51741	Complex uroflowmetry (eg, calibrated electronic equipment).
51797	Voiding pressure studies, intra-abdominal (ie, rectal, gastric, intraperitoneal) (List separately in addition to code for primary procedure).
51798	Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging.

ICD-10-CM Diagnosis Codes Supporting Medical NecessityICD-10Covered

A18.13	Tuberculosis of other urinary organs.
C70.1	Malignant neoplasm of spinal meninges.
C72.0	Malignant neoplasm of spinal cord.
C72.1	Malignant neoplasm of cauda equina.
D33.4	Benign neoplasm of spinal cord.
E10.69	Type 1 diabetes mellitus with other specified complications.
E11.69	Type 2 diabetes mellitus with other specified complication.
G20	Parkinson's disease.
G35	Multiple sclerosis.
G37.3	Acute transverse myelitis in demyelinating disease of central nervous system.

1–10 of 34

1/4

Additional ICD-10-CM Diagnosis Codes Supporting Medical Necessity for CPT 51798ICD-10Covered

N13.8	Other obstructive and reflux uropathy.
R33.0-R33.9	Retention of urine.
R35.0	Frequency of micturition.

Documentation and Utilization Requirements

Documentation Required

Complete the Initial Evaluation

Before urodynamic testing, perform and document an appropriate history, physical examination, and urinalysis with microscopy. The clinician must determine that testing offers additional diagnostic benefit beyond symptom assessment, examination, and other diagnostic studies, while weighing risks of urethral instrumentation, including infection, urethral trauma, and pain.

Documentation Required

Document a Qualifying Indication

Document the qualifying clinical indication and the rationale for medical necessity. Urodynamic testing is medically necessary to assist in diagnosing urologic dysfunction when at least one of the following applies: the diagnosis is uncertain and an initial treatment plan cannot be developed from clinical evaluation; an adequate therapeutic trial failed; urologic surgery is being considered, particularly after failed prior surgery or when the patient is at high surgical risk; or a qualifying comorbid condition is present.

Qualifying comorbidities include urinary incontinence; persistent difficult bladder emptying; prior anti-incontinence or radical pelvic surgery; symptomatic pelvic prolapse; prostate nodule, asymmetry, or other suspicion of prostate cancer; abnormal post-void residual urinalysis; diabetes mellitus with secondary urinary incontinence; neurologic conditions affecting voiding function, including neurogenic bladder from multiple sclerosis, Parkinson’s disease, or spinal cord lesions/injury; and complex anorectal malformation.

Urodynamic Testing Overview

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 identify abnormal voiding patterns in symptomatic patients. Testing is generally considered after a history, physical examination, and urinalysis, and conservative or empiric noninvasive treatment may be appropriate before invasive testing.

Definitions

Simple cystometrogram

DeviceA pressure catheter is inserted into the bladder.

Measurement methodA manometer records pressure and flow in the lower urinary tract.

ProcedureThis procedure is a simple cystometrogram (CPT 51725).

Complex cystometrogram

CatheterizationA transurethral catheter is used to fill the bladder.

Filling methodThe bladder is filled with water or gas.

Pressure measurementRectal pressure is obtained while a transducer measures intravesical pressure.

Policy Summary

PayerCommunity Care Independent Practice Association

PolicyUrodynamic Testing

Policy CodePolicy CP.MP.98

Change TypeModified

Effective DateN/A

Next Review DateN/A

Key ActionDocument an initial evaluation with an appropriate history, physical examination, and urinalysis with microscopy before urodynamic testing.

SourceLink

On This Page

An abnormal post-void residual or urinalysis is present.

Diabetes with secondary incontinence: Diabetes mellitus is present with secondary urinary incontinence.

Neurological voiding condition: A neurological condition affecting voiding function, such as neurogenic bladder due to multiple sclerosis, Parkinson's disease, or spinal cord lesion or injury, is present.

Complex anorectal malformation: A complex anorectal malformation is present.

Prior Authorization

Review Program-Specific Coverage Rules

Apply the coverage rules applicable to the member’s program before using this policy’s criteria. State Medicaid coverage provisions take precedence when they conflict with this policy; for Medicare members, review all applicable Medicare NCDs, LCDs, and Medicare Coverage Articles before applying these criteria.

For Medicaid members, consult the applicable state Medicaid manual.
For Medicare members, consult the CMS website and applicable NCDs, LCDs, and Coverage Articles.

Billing Rule

No Repeat Cystometrogram or Uroflowmetry in the Same Visit

Do not bill more than one cystometrogram or more than one uroflowmetry study during the same visit; such repeat testing is considered not medically necessary.

Cystometrogram codes affected: CPT 51725 and 51726.
Uroflowmetry codes affected: CPT 51736 and 51741.

Denial Risk

Do Not Perform Asymptomatic Screening

Urodynamic testing is not medically necessary for screening asymptomatic patients.

Exception: testing may be performed to evaluate neurogenic bladder or urologic abnormalities associated with complex anorectal malformation.

Denial Risk

Resolve Incomplete Evaluation or Untreated Infection

Do not proceed with urodynamic testing or other therapeutic interventions until the required initial evaluation is complete and any identified infection has been treated, with treatment effectiveness observed. Missing documentation of the history, physical examination, or urinalysis with microscopy—or testing during an untreated or inadequately evaluated infection—creates denial risk because urodynamic studies are indicated only after these prerequisites are satisfied.

Document the infection, treatment provided, and evidence that treatment was effective before proceeding.
Document the clinical rationale showing why urodynamic testing provides additional diagnostic benefit beyond symptoms, examination, and other diagnostic testing.

Uroflowmetry

DefinitionUroflowmetry records the volume of urine flow over time.

Simple measurementSimple uroflowmetry uses a stopwatch to record the volume of urine flow over time.

Complex measurementComplex uroflowmetry uses electronic equipment to measure and record the volume of urine flow over time.

Post-void residual measurement

PurposeThe measurement determines residual urine or bladder emptying capacity.

TimingThe measurement is performed after voiding.

MethodUltrasound is used to measure residual urine and/or bladder emptying capacity.

Health Plan

AdoptionA Health Plan is a health plan that has adopted this clinical policy.

Operation or administrationThe Health Plan is operated or administered, in whole or in part, by Centene Management Company, LLC, or one of its affiliates.

Policy relationshipThe Health Plan determines the effective date of this clinical policy.