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Urodynamic Testing to Evaluate Urinary Incontinence

Policy Number: MP-315

Latest Review Date:  August 2019

Category: Medical     

Policy Grade: Active Policy but no longer scheduled for regular literature reviews and updates.

Description of Procedure or Service:

Urinary incontinence affects up to 70% of community-dwelling women and up to 50% of nursing home residents.  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.  Most women with incontinence do not seek medical help.

Urodynamic testing refers to a group of tests used to assess function of the urinary tract by measuring various aspects of urine storage and evacuation.  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.

Policy:

Urodynamic testing in the evaluation of women with urinary incontinence 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).

Urodynamic testing in the evaluation of men may be considered medically necessary when the following indications are documented:

  1. Benign prostatic hypertrophy (BPH ) – uroflowmetry only.
  2. Pressure flow studies for the evaluation of urinary symptoms in men with maximum flow rates above 10ml./sec. with abnormal presentations .
  3. For the evaluation of urinary symptoms in men who have failed prior invasive therapy for the treatment of BPH.
  4. The patient has a history of extensive pelvic surgeries, prior radiation therapy to the pelvis, or has neurological abnormalities.

Key Points:

The purpose of urodynamic testing is to aid in understanding physiologic mechanisms of lower urinary tract dysfunction, thereby improving the accuracy of diagnosis and facilitating targeted treatment.

There are some pitfalls 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.  Also, the artificial situation of the urodynamic lab may produce non-physiologic results.  There may also be inconsistent reproducibility of test results in the same patient.  There is a wide range of physiologic values in normal, asymptomatic patients.  The absence of a specific abnormality during urodynamic testing does not exclude its existence, and not all abnormalities found during urodynamics are clinically significant.  There are also variations in the qualifications and experience of the testers.  There is controversy over the choice of which test to do (e.g., non-invasive flow, filling cystometrogram, pressure-flow studies) and when they should be repeated.  These criteria influence the plausibility and validity of the study results.  Thus, an urodynamic test is not definitive and must be placed in the context of the entire evaluation.

The indications for urodynamic testing remain controversial.  Current consensus statements and practice recommendations recommend conservative treatment prior to any urodynamic tests.  A consensus on the indications for preoperative urodynamic studies in the evaluation of SUI is lacking.  There are some situations in which testing may be useful.  Below, the absolute indications for urodynamic testing from three different societies are summarized.

The Agency for Health Care Policy and Research recommends that urodynamic testing be done in these types of patients:  surgical intervention is planned in a high surgical risk patient, uncertain diagnosis, symptomatic pelvic-organ prolapse, neurologic abnormalities, prior incontinence procedures, or radical pelvic surgery.

The following are the grade descriptions for pelvic organ prolapse:

· Grade I—halfway to the hymen

· Grade II –at the hymen

· Grade III—halfway out of the hymen

· Grade IV—total prolapse

The American College of Obstetrics and Gynecology (ACOG) recommends that urodynamic testing be done in patients with these conditions:  mixed symptoms (stress and urge urinary incontinence), failure of prior incontinence procedures, to exclude detrusor overactivity, to identify potential risk factors for surgical failure, and to determine voiding mechanism.

The International Consultation on Incontinence recommends that urodynamic testing be done in patients with complicated cases of urinary incontinence, uncertain pathophysiology, or neurogenic voiding dysfunction.

The ACOG also specifically addressed the issue of urodynamic testing before surgery.  They stated that these types of patients may not need urodynamic testing prior to surgery:  non-pregnant women who lose urine only with physical exertion and have normal voiding habits (i.e., less than 8 voiding episodes per day and 2 per night); no associated neurologic or physical findings; no history of anti-incontinence or radical pelvic surgery; a hypermobile urethra, pliable vaginal wall, and adequate vaginal capacity on physical exam; and a normal post-void residual volume.

In summary, the indications for urodynamic testing are still heavily debated.  They should be performed to address a specific question and should attempt to reproduce the patient’s symptoms.  The potential limitations of the test should be understood and acknowledge by the physician who interprets the results.  The study should not be read in isolation, but should be integrated into the overall clinical picture.

Male Incontinence

Urinary incontinence may also be seen in men.  Detrusor overactivity and outlet obstruction are the most common causes of urinary incontinence in older men.  Detrusor overactivity occurs in approximately 2/3 of men with obstruction, resulting in urgency and, less frequently, urge incontinence.  Outlet obstruction may be a result of benign prostatic hyperplasia, prostate cancer, or urethral stricture.  Most obstructed men, however, do not have urinary incontinence.  Incontinence associated with obstruction often presents as post-void dribbling.  One cause of stress incontinence in men is prostate surgery.

Benign prostatic hyperplasia (BPH) is a common disorder that is more frequent in men older than age 50 years.  The clinical manifestations are lower urinary tract symptoms that include increased frequency of urination, nocturia, hesitancy, urgency, and weak urinary stream.  The evaluation for BPH includes a history, physical exam, urinalysis, and serum creatinine.  There are several other tests that may be performed as part of the evaluation of men with BPH, but the American Urological Association (AUA) considers them optional.  These tests include the serum prostate specific antigen (PSA), maximal urinary flow rate, and post-void residual urine volume.  Although these tests are optional, they are useful in most men.  Another urodynamic test, the pressure flow study, is usually reserved for men with urinary symptoms and maximal flow rates above 15 mL/sec and those in whom the clinical manifestations are atypical and there is reason to suspect some problem other than or in addition to BPH.

The European Association of Urology (EAU) issued guidelines in 2004 in the assessment, therapy, and follow-up of men with lower urinary tract symptoms suggestive of benign prostatic obstruction (BPO).  They recommended these tests for the initial assessment:  medical history, physical examination including digital-rectal examination, International Prostate Symptom Score, urinalysis, serum creatinine and prostate specific antigen measurement, uroflowmetry and post-void residual volume.  All other tests are optional or not recommended.

The Canadian Urological Association (CUA) issued guidelines in 2005 for the management of lower urinary tract symptoms in men with benign prostatic hyperplasia (BPH).  They stated that the mandatory evaluation should include history, physical examination and urinalysis, while a symptom inventory and PSA in selected patients are recommended.  They stated that serum creatinine, uroflow, voiding diary, post-void residual, and sexual function questionnaire are optional.

Parkinson’s disease (PD) is a chronic, progressive neurodegenerative disorder that is characterized by four cardinal signs:  rest tremor, rigidity, bradykinesia, and gait disturbance.  One complication of PD is urinary incontinence.  Testing of autonomic function, including urodynamic testing, urethral or anal sphincter EMG, or sympathetic skin responses, has been examined as a potential tool for differentiating PD from other parkinsonian syndromes, especially multiple system atrophy (MSA).  These tests, however, are generally not widely available, and there is insufficient evidence to recommend their routine use as diagnostic tests for PD.

Key Words:

Urodynamic testing, urinary stress incontinence

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.

For these studies to be covered, urodynamic testing and the interpretation of the tests must be done in the office, clinic, or facility of a participating provider and, if sent elsewhere for interpretation, be interpreted by a participating provider.

ITS: Home Policy provisions apply

FEP contracts: Special benefit consideration may apply.  FEP does not consider investigational if FDA approved and will be reviewed for medical necessity.

Current Coding

CPT codes:

51725              Simple cystometrogram (CMG) (e.g., spinal manometer)
51726              Complex cystometrogram (i.e., calibrated electronic equipment)
51727              Complex cystometrogram (i.e., calibrated electronic equipment); with urethral pressure profile studies (i.e., urethral closure pressure profile), and technique
51728              Complex cystometrogram (i.e., calibrated electronic equipment); with voiding pressure studies (i.e., bladder voiding pressure), any technique
51729              Complex cystometrogram (i.e., calibrated electronic equipment); with voiding pressure studies (i.e., bladder voiding pressure) and urethral pressure profile studies (i.e., urethral closure pressure profile), any technique
51736              Simple uroflowmetry (UFR) (e.g., stop-watch flow rate, mechanical uroflowmeter)
51741              Complex uroflowmetry (e.g., calibrated electronic equipment)
51784              Electromyography studies (EMG) of anal or urethral sphincter, other than needle, any technique
51785              Needle electromyography studies (EMG) of anal or urethral sphincter, any technique
51792              Stimulus evoked response (e.g., measurement of bulbocavernosus reflex latency time)
51797              Voiding pressure studies, intra-abdominal (i.e., 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

 

References:

  1. ACOG Practice Bulletin.  Urinary Incontinence in Women.  Obstetrics and Gynecology, June 2005, No. 63.
  2. Buchsbaum GM, et al.  Urinary incontinence in nulliparous women and their parous sisters.  Obstetrics and Gynecology, December 2005, Vol. 106, No. 6, pp. 1253-1258.
  3. 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. 76-8
  4. Chou KL.  Diagnosis of Parkinson’s disease.  Up To Date 2008.  http://www.utdol.com.
  5. Cunningham GR.  Diagnosis of benign prostatic hyperplasia.  Up To Date 2008.  http://www.utdol.com.
  6. DuBeau CE.  Clinical presentation and diagnosis of urinary incontinence.  Up To Date 2008, http://www.utdol.com.
  7. 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.
  8. Flesh G.  Urodynamic evaluation of women with incontinence.  http://www.uptodate.com, August 2007.
  9. Handa VL, et al.  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.
  10. 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.
  11. Lemak GE, Krauss S, et al.  Normal preoperative urodynamic testing does not predict voiding dysfunction after Burch colposuspension versus pubovaginal sling.  J Radiol 2008; 180(5): 2076-2080.
  12. 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.
  13. 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.
  14. Mutone M, et al.  Practical evaluation of the incontinent woman.  http://www.femalepatient.com.
  15. 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.
  16. Nickel JC, et al.  Canadian guidelines for the management of benign prostatic hyperplasia.  Canadian Journal of Urology, June 2005; 12(3): 2677-2783.
  17. O’Connell HE, et al.  Evaluation of female urinary incontinence.  Medscape General Medicine 1999; 1(1).  http://www.medscape.com.
  18. Ogundele O, et al.  Urinary incontinence.  http://www.emedicine.com, July 2006.
  19. Rosenzweig BA, et al.  Prevalence of abnormal urodynamic test results in continent women with severe genitourinary prolapse.  Obstetrics and Gynecology 1992; 79: 539-542.
  20. Subak LL, et al.  The “costs” of urinary incontinence for women.  Obstetrics and Gynecology, April 2006, Vol. 107, No. 4, pp. 908-916.
  21. 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.
  22. 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.
  23. Weber AM, et al.  The cost-effectiveness of preoperative testing (basic office assessment vs. urodynamics) for stress urinary incontinence in women.  BJU International 2002; 89: 356-363.
  24. 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.

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.