Latest Review Date: February 2024

Category: Medical                                                     

POLICY:

Urodynamic testing may be considered medically necessary when any of the following indications are documented:

1. The diagnosis with respect to the type of urinary incontinence is uncertain, after the initial history and physical examination.
2. The patient’s symptoms do not correlate with the objective physical findings.
3. The patient has mixed symptoms (stress and urge urinary incontinence).
4. The patient fails to improve with treatment or has failure of prior incontinence procedures.
5. The patient is being considered for surgical intervention and has a complicated diagnostic situation and is at high surgical risk.
6. The patient has a history of extensive pelvic surgeries, prior radiation therapy to the pelvis, or has neurologic abnormalities.
7. The patient has symptomatic pelvic organ prolapse (Grade III or higher).
8. Benign prostatic hypertrophy (BPH) – uroflowmetry only.
9. Pressure flow studies for the evaluation of urinary symptoms in patients with maximum flow rates above 10ml/sec. with abnormal presentations.
10. For the evaluation of urinary symptoms in patients who have failed prior invasive therapy for the treatment of BPH.
11. The patient has a history of extensive pelvic surgeries, prior radiation therapy to the pelvis, or has neurological abnormalities.

DESCRIPTION OF PROCEDURE OR SERVICE:

Urinary incontinence (UI) is common and may affect up to 50% of adult women and up to 11% of men.  Prevalence increases gradually during young adulthood, peaks broadly around middle age, and then steadily increases in the elderly.  In up to 75% of ambulatory women with incontinence, urodynamic stress incontinence is the main condition.  Detrusor overactivity accounts for up to 33% of incontinence cases, with the remainder being mixed forms. 

Urodynamic testing refers to a group of tests used to assess function of the urinary tract by measuring various aspects of urine storage and emptying.  Some types of urodynamic testing include:

• Cystometry measures bladder pressure during bladder filling.  It is used to assess detrusor activity and bladder sensation, capacity, and compliance.  Cystometry can be simple and office based or it can be multichannel, including measurement of intra-abdominal, bladder, and detrusor (bladder minus intra-abdominal) pressures. 
• Uroflowmetry measures urine volume voided over time.  It can be done with or without a pressure-flow study.
• Pressure flow study measures both bladder pressure and urinary flow.  It determines the mechanism of abnormal voiding revealed by a low flow rate on uroflowmetry.
• Urethral pressure profile measures the intraluminal pressure along the urethra with the bladder at rest.
• Leak point pressure refers to the amount of abdominal pressure required to overcome urethral resistance and produce urine leakage when the patient is not trying to void.  The pressure can be produced by Valsalva or cough.
• Post-void residual volume measurement is made by straight catheterization or by bladder ultrasound.  A high volume on repeat determinations indications outlet obstruction or poor detrusor contractility.
• Video urodynamics is similar to conventional cystometry, but with the addition of a radio-opaque filling medium, video recorder, and x-ray equipment.  Most authorities think it is seldom indicated.

KEY POINTS:

A literature review was performed through February 15, 2024.

Summary of Evidence

For patients receiving urodynamic testing, the evidence consists of systematic reviews and prospective studies.  There are some limitations in urodynamic testing that limit its value.  These include lack of standardization of technical details, such as patient position, type of pressure sensor, and filling rate.  These variables can affect results.   Consensus statements and practice recommendations agree that conservative treatment should be done prior to any urodynamic tests. There is agreement for certain situations in which urodynamic testing may be useful and should be performed after an initial evaluation that includes an appropriate history, physical exam, and urinalysis with microscopy.

Practice Guidelines and Position Statements

American Urological Association and Society for Urodynamics

In 2012, the AUA and SUFU developed a guideline regarding adult urodynamics.

Stress Urinary Incontinence (SUI)/Prolapse

1. Clinicians who are making the diagnosis of urodynamic stress incontinence should assess urethral function. (Recommendation; Evidence Strength: Grade C)
2. Surgeons considering invasive therapy in patients with SUI should assess post-void residual (PVR) urine volume. (Expert Opinion)
3. Clinicians may perform multi-channel urodynamics in patients with both symptoms and physical findings of stress incontinence who are considering invasive, potentially morbid or irreversible treatments.  (Option; Evidence Strength: Grade C)
4. Clinicians should perform repeat stress testing with the urethral catheter removed in patients suspected of having SUI who do not demonstrate this finding with the catheter in place during urodynamic testing.  (Recommendation; Evidence Strength: Grade C)
5. Clinicians should perform stress testing with reduction of the prolapse in women with high grade pelvic organ prolapse (POP) but without the symptom of SUI. Multi-channel urodynamics with prolapse reduction may be used to assess for occult stress incontinence and detrusor dysfunction in these women with associated LUTS.  (Option; Evidence Strength: Grade C)

Overactive Bladder (OAB), Urgency Urinary Incontinence (UUI), Mixed Incontinence

6. Clinicians may perform multi-channel filling cystometry when it is important to determine if altered compliance, detrusor overactivity or other urodynamic abnormalities are present (or not) in patients with urgency incontinence in whom invasive, potentially morbid or irreversible treatments are considered.  (Option; Evidence Strength: Grade C)
7. Clinicians may perform pressure flow studies (PFS) in patients with urgency incontinence after bladder outlet procedures to evaluate for bladder outlet obstruction. (Expert Opinion)
8. Clinicians should counsel patients with urgency incontinence and mixed incontinence that the absence of detrusor overactivity (DO) on a single urodynamic study does not exclude it as a causative agent for their symptoms. (Clinical Principle)

Neurogenic Bladder (NGB)

9. Clinicians should perform PVR assessment, either as part of a complete urodynamic study or separately, during the initial urological evaluation of patients with relevant neurological conditions (e.g., spinal cord injury and myelomeningocele) and as part of ongoing follow-up when appropriate.  (Standard; Evidence Strength: Grade B)
10. Clinicians should perform a complex cystometrogram (CMG) during initial urological evaluation of patients with relevant neurological conditions with or without symptoms and as part of ongoing follow-up when appropriate. In patients with other neurological diseases, physicians may consider CMG as an option in the urological evaluation of patients with LUTS. (Recommendation; Evidence Strength: Grade C)
11. Clinicians should perform pressure flow analysis during the initial urological evaluation of patients with relevant neurological conditions with or without symptoms and as part of ongoing follow-up when appropriate, in patients with other neurologic disease and elevated PVR or in patients with persistent symptoms.  (Recommendation, Evidence Strength: Grade C) 
12. When available, clinicians may perform fluoroscopy at the time of urodynamics (videourodynamics) in patients with relevant neurologic disease at risk for neurogenic bladder, in patients with other neurologic disease and elevated PVR or in patients with urinary symptoms. (Recommendation; Evidence Strength: Grade C)
13. Clinicians should perform electromyography (EMG) in combination with CMG with or without PFS in patients with relevant neurologic disease at risk for neurogenic bladder, in patients with other neurologic disease and elevated PVR or in patients with urinary symptoms. (Recommendation; Evidence Strength: Grade C)

LUTS

14. Clinicians may perform PVR in patients with LUTS as a safety measure to rule out significant urinary retention (UR) both initially and during follow up. (Clinical Principle)
15. Uroflow may be used by clinicians in the initial and ongoing evaluation of male patients with LUTS when an abnormality of voiding/emptying is suggested. (Recommendation; Evidence Strength: Grade C)
16. Clinicians may perform multi-channel filling cystometry when it is important to determine if DO or other abnormalities of bladder filling/urine storage are present in patients with LUTS, particularly when invasive, potentially morbid or irreversible treatments are considered.  (Expert Opinion)
17. Clinicians should perform PFS in men when it is important to determine if urodynamic obstruction is present in men with LUTS, particularly when invasive, potentially morbid or irreversible treatments are considered.  (Standard: Evidence Strength: Grade B)
18. Clinicians may perform PFS in women when it is important to determine if obstruction is present.  (Option; Evidence Quality: Grade C)
19. Clinicians may perform videourodynamics in properly selected patients to localize the level of obstruction, particularly for the diagnosis of primary bladder neck obstruction. (Expert Opinion) 

In 2019, the AUA and SUFU published a guideline for Incontinence after Prostate Treatment which states that “Clinicians may perform urodynamic testing in a patient prior to surgical intervention for stress urinary incontinence in cases where it may facilitate diagnosis or counseling. (Conditional Recommendation; Evidence Level C)

U.S. Preventive Services Task Force

N/A

KEY WORDS:

Urodynamic testing, Urodynamic studies, urinary stress incontinence, incontinence, mixed incontinence, organ prolapse, prostate

APPROVED BY GOVERNING BODIES:

Not applicable

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group-specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP: Special benefit consideration may apply. Refer to the member's benefit plan.  

CURRENT CODING

CPT codes:

REFERENCES:

1. American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin No. 155.  Urinary Incontinence in Women.  Obstet Gyn, 2015 Nov, 126(5);e66-81.
2. American Urological Association (AUA). Adult Urodynamics: AUA/SUFU Guideline.  Available at: www.auanet.org/guidelines/urodynamics-guideline.J Urol. 2012 Dec;188(6 Suppl):2464-72.
3. American Urological Association (AUA). Incontinence after Prostate Treatment: AUA/SUFU Guideline (2019).  Available at: www.auanet.org//guidelines-and-quality/guidelines/incontinence-after-prostate-treatment.
4. Aponte MM, Shah SR, Hickling D, Brucker BM, Rosenblum N, Nitti VW. Urodynamics for clinically suspected obstruction after anti-incontinence surgery in women. J Urol. 2013;190(2):598-602.
5. Brucker BM, Nitti VW. Urodynamic and video-urodynamic evaluation of the lower urinary tract. In: Partin AW, Dmochowski RR, Kavoussi LR, Peters CA, eds. Campbell-Walsh-Wein Urology. 12th ed. Philadelphia, PA: Elsevier; 2021:chap 114.
6. Bump RC, et al.  Mixed urinary incontinence symptoms:  Urodynamic findings, incontinence severity, and treatment response.  Obstetrics and Gynecology, July 2003, Vol. 102, No. 1, pp. 76-83.
7. Cameron AP, Campeau L, Brucker BM, et al. Best practice policy statement on urodynamic antibiotic prophylaxis in the non-index patient. Neurourol Urodyn. 2017;36(4):915-926.
8. Cooper MA, Fletter PC, Zaszczurynski PJ, Damaser MS. Comparison of air-charged and water-filled urodynamic pressure measurement catheters. Neurourol Urodyn. 2011;30(3):329-334.
9. DuBeau CE.  Clinical presentation and diagnosis of urinary incontinence.  Up To Date 2008, www.utdol.com.
10. Fallon B, et al.  Urodynamic assessment of sphincteric function in the incontinent female:  Which test, and does it matter anyway?  Current Urology Reports, September 2006; 7(5): 399-404.
11. Flesh G.  Urodynamic evaluation of women with incontinence.  www.uptodate.com, August 2007.
12. Handa VL, Jensen, J.K. & Ostergard, D.R.  Federal guidelines for the management of urinary incontinence in the United States:  Which patients should undergo urodynamic testing?  International Urogynecology Journal, July 1995, Vol. 6, No. 4, 198-203.
13. IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
14. Kaplan SA, Kohler TS, Kausik SJ. Noninvasive pressure flow studies in the evaluation of men with lower urinary tract symptoms secondary to benign prostatic hyperplasia: a review of 50,000 patients. J Urol. 2020;204:1296-1304.
15. Karram MM, et al.  Factors affecting detrusor contraction strength during voiding in women.  Obstetrics and Gynecology, November 1997, Vol. 90, No. 5, pp. 723-726.
16. Kim M, Jeong CW, Oh SJ. Diagnostic value of urodynamic bladder outlet obstruction to select patients for transurethral surgery of the prostate: Systematic review and meta-analysis. PLoS One. 2017 Feb 27;12(2):e0172590.
17. Lec PM, Nitti VW. Bladder outlet obstruction in women: Advanced evaluation. Neurourol Urodyn. 2024 Jan 30.
18. Lemak GE, Krauss S, et al.  Normal preoperative urodynamic testing does not predict voiding dysfunction after Burch colposuspension versus pubovaginal sling.  J Radiol 2008 Nov; 180(5): 2076-2080.
19. Lentz GM, Miller JL. Lower urinary tract function and disorders: physiology of micturition, voiding dysfunction, urinary incontinence, urinary tract infections, and painful bladder syndrome. In: Gershenson DM, Lentz GM, Valea FA, Lobo RA, eds. Comprehensive Gynecology. 8th ed. Philadelphia, PA: Elsevier; 2022:chap 21.
20. Madersbacher S, et al.  EAU 2004 guidelines on assessment, therapy, and follow-up of men with lower urinary tract symptoms suggestive of benign prostatic obstruction (BPH guidelines).  European Urology, November 2004; 46(5): 547-554.
21. Murdoch M, McColl E, et al. INVESTIGATE-1 (INVasive Evaluation before Surgical Treatment of Incontinence Gives Added Therapeutic Effect?): study protocol for a mixed methods study to assess the feasibility of a future randomized controlled trial of the clinical utility of invasive urodynamic testing. Trials, July 2011; 12:169.
22. Nager CW, Brubaker L, et al. Design of the Value of Urodynamic Evaluation (ValUE) trial: a non-inferiority randomized trial of preoperative urodynamic investigations. Contemporary Clinical Trials, November 2009; 30(6):531-539.
23. Nickel JC, et al.  Canadian guidelines for the management of benign prostatic hyperplasia.  Canadian Journal of Urology, June 2005; 12(3): 2677-2783.
24. Okorocha I, Cumming G, Gould I. Female urodynamics and lower urinary tract infection. BJU Int. 2002;89(9):863-867.
25. Pang KH, Campi R, Arlandis S, et al. Diagnostic tests for female bladder outlet obstruction: a systematic review from the European Association of Urology non-neurogenic female LUTS guidelines panel. Eur Urol Focus. 2022;8(4):1015-1030.
26. Rosier PFWM, Schaefer W, Lose G, et al. International Continence Society good urodynamic practices and terms 2016: urodynamics, uroflowmetry, cystometry, and pressure-flow study. Neurourol Urodyn. 2017;36(5):1243-1260.
27. Subak LL, et al.  The “costs” of urinary incontinence for women.  Obstetrics and Gynecology, April 2006, Vol. 107, No. 4, pp. 908-916.
28. Swift SE, et al.  Evaluation of current urodynamic testing methods in the diagnosis of genuine stress incontinence.  Obstetrics and Gynecology, July 1995, Vol. 86, No. 1, pp. 85-91.
29. Syan R, Brucker BM. Guideline of guidelines: urinary incontinence. BJU Int. 2016 Jan;117(1):20-33.
30. Takacs EB, et al.  Recommendations for urodynamic assessment in the evaluation of women with stress urinary incontinence.  Nature Clinical Practice Urology, October 2006; 3(10): 544-550.
31. Weber AM, et al.  The cost-effectiveness of preoperative testing (basic office assessment vs. urodynamics) for stress urinary incontinence in women.  BJU International 2002 Mar; 89(4): 356-363.
32. Whiteside JL, et al.  Reliability and agreement of urodynamics interpretations in a female pelvic medicine center.  Obstetrics and Gynecology, August 2006, Vol. 108, No. 2, pp. 315-323.

POLICY HISTORY:

Medical Policy Group, October 2008 (4)
Medical Policy Administration Committee, November 2008
Available for comment November 6-December 19, 2008
Medical Policy Group, January 2010 (1)
Medical Policy Group, September 2011(3); Updated Key Points and References
Medical Policy Group, September 2012 (3): Effective September 14, 2012 this policy is no longer scheduled for regular literature reviews and updates.
Medical Policy Group, August 2019 (5); Reviewed by consensus. No new published peer-reviewed literature available that would alter the coverage statement in this policy.
Medical Policy Group, February 2021 (4): Updates to Key Points, Key Words, and References.  No change to policy statements.  Added key words Urodynamic studies, incontinence, mixed incontinence, organ prolapse, prostate, 
Medical Policy Group, February 2022 (4): Reviewed by consensus. Reference added. No new published peer-reviewed literature available that would alter the coverage statement in this policy. 

Medical Policy Group, February 2023 (4): Reviewed by consensus.  Updates to Key Points and References.  No new published peer-reviewed literature available that would alter the coverage statement in this policy.

Medical Policy Group, February 2024 (11): Reviewed by consensus.  Updates to Description, Key Points, Benefit Application and References.  No new published peer-reviewed literature available that would alter the coverage statement in this policy.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.