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    v1.0.30
    OpenPayerPolicy UpdatesUrologyDHA Urinary Surgery Policy Update | OpenPayer
    Ask Trek AI about this page
    ModifiedDHAPolicy 6010.63-M

    Urinary System Surgery

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    This policy addresses surgical services involving the urinary system within the DHA surgery policy manual. The available document window contains only the table-of-contents listing and does not provide clinical coverage criteria or operational requirements.

    Policy Summary
    PayerDHA
    PolicyUrinary System Surgery
    Policy CodePolicy 6010.63-M
    Change TypeModified
    Effective DateJanuary 1, 2020
    Next Review DateN/A
    Key ActionDocument failed conservative treatment and a successful peripheral nerve evaluation test before seeking coverage for sacral nerve root stimulation.
    SourceLink
    POLICY UPDATE CHANGES

    Transurethral waterjet ablation of the prostate using CPT code 0421T was added as a covered treatment for benign prostatic hyperplasia.

    Transurethral needle ablation (TUNA) of the prostate using CPT code 53852 was added as a proven treatment for benign prostatic hyperplasia.

    1Urinary system surgery sections
    7Listed procedure codes
    4

    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.

    Proven or covered procedures
    6Excluded or unproven services
    3Sacral stimulation conditions
    2Rare-disease ablation approaches

    Covered, Proven, and Unproven Services

    Sacral Nerve Root Stimulation

    Services and supplies related to implantation may be covered when all of the following are met.

    Sacral nerve root stimulation criteria: The individual has urge incontinence, non-obstructive urinary retention, or symptoms of urgency-frequency syndrome that are not due to a neurologic condition; previous conservative treatments have failed; and a peripheral nerve evaluation test was successful.

    The device must be similar to a U.S. Food and Drug Administration-approved device. Sacral Nerve Root Stimulation has received FDA approval.

    Primary Nocturnal Enuresis Bedwetting Alarm

    The service may be considered for cost-sharing when all of the following are met.

    Bedwetting alarm criteria: The alarm is prescribed by a physician, and physical or organic causes of primary nocturnal enuresis have been ruled out.

    Collagen Implantation

    The procedure may be covered when the following condition is met.

    Collagen implantation criterion: The patient is not amenable to other forms of urinary incontinence treatment.

    Applies to collagen implantation of the urethra and/or bladder neck.

    Renal Cell Carcinoma Cryoablation

    Coverage may be considered under the Rare Disease policy on a case-by-case basis.

    Renal cell carcinoma cryoablation criterion: The treatment is cryoablation for renal cell carcinoma.case-by-case

    Review is required under the Rare Disease policy. CPT codes 50250 and 50593 are identified.

    Renal Cell Carcinoma Radiofrequency Ablation

    Coverage may be considered under the Rare Disease policy on a case-by-case basis when all of the following are met.

    Renal cell carcinoma radiofrequency ablation criteria: The treatment is laparoscopic radiofrequency ablation or percutaneous radiofrequency ablation for renal cell carcinoma or a genetic syndrome associated with renal cell carcinoma, including von Hippel-Lindau syndrome, hereditary papillary cell carcinoma, or hereditary clear-cell carcinoma; and the patient is not an appropriate candidate for surgical intervention.case-by-case

    CPT codes 50542 and 50592 are identified.

    Posterior Tibial Nerve Stimulation

    The procedure is identified as proven for the following indication.

    PTNS indication: Posterior tibial nerve stimulation is used to treat overactive bladder, including urinary frequency, urge, and incontinence.

    CPT code 64566.

    Prostatic Urethral Lift

    The procedure is identified as proven for the following indication.

    PUL indication: Prostatic urethral lift is used to treat urinary outflow obstruction secondary to benign prostatic hyperplasia.

    CPT codes 52441 and 52442; HCPCS codes C9739 and C9740.

    Transurethral Needle Ablation

    The procedure is identified as proven for the following indication.

    TUNA indication: Transurethral needle ablation is used to treat benign prostatic hyperplasia.

    CPT code 53852.

    Transurethral Waterjet Ablation

    The procedure is covered for the following indication.

    Transurethral waterjet ablation indication: Transurethral waterjet ablation of the prostate is used to treat benign prostatic hyperplasia.

    CPT code 0421T; effective January 1, 2020.

    Peri-urethral Teflon injection is unproven under this policy and is not eligible for coverage on that basis.

    Silastic gel implants are excluded from coverage under this policy.

    Acrylic prostheses, also called Berry prostheses, are excluded from coverage under this policy.

    Bladder stimulators are excluded, whether direct or indirect, including spinal cord, rectal, vaginal electrical, and bladder wall stimulators. Payment is also excluded for any related service or supply, including inpatient hospitalization primarily for surgical implantation of a bladder stimulator.

    Transurethral balloon dilation of the prostate is unproven. This applies to CPT code 52510.

    Cryoablation for treatment of renal angiomyolipoma is unproven under this policy.

    Covered and Non-Covered Procedure Codes

    CPT CodesCPT
    50010-53899CPT code range
    64561CPT code
    64581CPT code
    64585CPT code
    64590CPT code
    64595CPT code
    0421TAdded in Revision 28, January 8, 2025
    Renal Cell Carcinoma CryoablationCPT
    50250Cryoablation for renal cell carcinoma
    50593Cryoablation for renal cell carcinoma
    Renal Cell Carcinoma Radiofrequency AblationCPT
    50542Laparoscopic Radiofrequency Ablation (RFA)
    50592Percutaneous Radiofrequency Ablation (PRFA)
    Proven PTNSCPTCovered
    64566Posterior Tibial Nerve Stimulation (PTNS) for treatment of overactive bladder, to include urinary frequency, urge, and incontinence
    Proven PULmixedCovered
    52441Prostatic Urethral Lift (PUL) for treatment of urinary outflow obstruction secondary to Benign Prostatic Hyperplasia (BPH)
    52442Prostatic Urethral Lift (PUL) for treatment of urinary outflow obstruction secondary to Benign Prostatic Hyperplasia (BPH)
    C9739Prostatic Urethral Lift (PUL) for treatment of urinary outflow obstruction secondary to Benign Prostatic Hyperplasia (BPH)
    C9740Prostatic Urethral Lift (PUL) for treatment of urinary outflow obstruction secondary to Benign Prostatic Hyperplasia (BPH)
    Proven TUNACPTCovered
    53852Transurethral needle ablation (TUNA) for treatment of BPH
    Covered Transurethral Waterjet AblationCPTCovered
    0421TTransurethral waterjet ablation of the prostate for treatment of BPH
    Excluded or UnprovenCPTNot Covered
    52510Transurethral balloon dilation of the prostate

    Documentation and Review Requirements

    Documentation Required

    Sacral Nerve Stimulation: Conservative Treatment and Nerve Evaluation

    Before sacral nerve root stimulation, document that the patient has failed previous conservative treatments and has had a successful peripheral nerve evaluation test.

    • Applicable conditions include urge incontinence, non-obstructive urinary retention, or urgency-frequency syndrome not due to a neurologic condition.
    Documentation Required

    Other Incontinence Treatments Must Be Unsuitable

    Document that the patient is not amenable to other forms of urinary incontinence treatment before seeking coverage for collagen implantation of the urethra and/or bladder neck.

    Documentation Required

    Sacral Nerve Stimulation Clinical Documentation

    Policy Scope and Clinical Context

    The urinary system comprises the organs involved in the production and excretion of urine. This policy addresses surgical services for urinary-system conditions, including urinary incontinence, nocturnal enuresis, urinary retention, overactive bladder, benign prostatic hyperplasia, renal cell carcinoma, and related illness or injury. Coverage may depend on prior conservative treatment, diagnostic evaluation, disease-specific appropriateness, or case-by-case review under applicable rare-disease provisions.

    Key Terms and Abbreviations

    Definitions
    TermUrinary system
    DefinitionThose organs concerned in the production and excretion of urine.
    FunctionsProduction of urine; excretion of urine
    Definitions
    AbbreviationSNS
    Full termSacral Nerve Root Stimulation
    DefinitionStimulation of the sacral nerve roots; the SNS has received FDA approval.
    Policy Summary
    PayerDHA
    PolicyUrinary System Surgery
    Policy CodePolicy 6010.63-M
    Change TypeModified
    Effective DateJanuary 1, 2020
    Next Review DateN/A
    Key ActionDocument failed conservative treatment and a successful peripheral nerve evaluation test before seeking coverage for sacral nerve root stimulation.
    SourceLink
    On This Page
    Covered, Proven, and Unproven ServicesCovered and Non-Covered Procedure CodesDocumentation and Review RequirementsPolicy Scope and Clinical ContextKey Terms and Abbreviations

    For sacral nerve stimulation, submit clinical documentation supporting an eligible diagnosis and the required treatment history and testing.

    • Urge incontinence
    • Non-obstructive urinary retention
    • Urgency-frequency syndrome not due to a neurologic condition
    • Failed previous conservative treatments
    • Successful peripheral nerve evaluation test
    Documentation Required

    Bedwetting Alarm Documentation

    A bedwetting alarm for primary nocturnal enuresis may be considered when prescribed by a physician and after physical or organic causes of nocturnal enuresis have been ruled out.

    • Include the physician prescription.
    • Document that physical or organic causes have been ruled out.
    Documentation Required

    Collagen Implantation Documentation

    For collagen implantation of the urethra and/or bladder neck, document that the patient is not amenable to other forms of urinary incontinence treatment.

    • Apply this requirement to collagen implantation for urinary incontinence.
    Denial Risk

    Excluded or Unproven Urinary Procedures

    The following urinary procedures and services are excluded or unproven and may be denied.

    • Peri-urethral Teflon injection — unproven
    • Silastic gel implant
    • Acrylic prosthesis (Berry prosthesis)
    • Bladder stimulators, including spinal cord, rectal, vaginal electrical, or bladder wall stimulators; related services or supplies and inpatient hospitalization primarily for implantation are also excluded
    • Transurethral balloon dilation of the prostate (CPT 52510) — unproven
    • Cryoablation for renal angiomyolipoma — unproven
    Prior Authorization

    Renal Cell Carcinoma Cryoablation Requires Rare-Disease Review

    Cryoablation for renal cell carcinoma may be considered under the Rare Disease policy only through case-by-case review.

    • CPT 50250 and 50593
    • Apply the Rare Disease policy review pathway.
    Prior Authorization

    RFA Requires Case-by-Case Consideration

    Laparoscopic or percutaneous radiofrequency ablation may be considered on a case-by-case basis under the Rare Disease provisions when the clinical requirements are met.

    • Laparoscopic RFA: CPT 50542
    • Percutaneous RFA (PRFA): CPT 50592
    • Applicable to renal cell carcinoma or associated genetic syndromes, including von Hippel-Lindau syndrome, hereditary papillary cell carcinoma, or hereditary clear-cell carcinoma
    • Document that the patient is not an appropriate candidate for surgical intervention.
    Definitions
    AbbreviationPTNS
    Full termPosterior Tibial Nerve Stimulation
    IndicationTreatment of overactive bladder, including urinary frequency, urge, and incontinence.
    Definitions
    AbbreviationPUL
    Full termProstatic Urethral Lift
    IndicationTreatment of urinary outflow obstruction secondary to benign prostatic hyperplasia.