BlueCross BlueShield of Tennessee Medical Policy Manual

Genitourinary System

• Balloon Dilatation of the Prostatic Urethra

• Biofeedback

• Biothesiometry for Erectile Dysfunction

• Corporal Cavernosal Electromyography for Erectile Dysfunction

• Cryosurgical Ablation for the Treatment of Prostate Tumors

• Cryosurgical Ablation for Treatment of Renal Tumors

• Daily Hemodialysis in the Home

• Diagnostic Labwork for Erectile Dysfunction

• Duplex Ultrasonography for Erectile Dysfunction

• Dynamic Infusion Cavernosometry and Cavernosography for Erectile Dysfunction

• Enuresis Alarms

• Erythropoiesis-Stimulating Agents (ESAs)

• Evoked Potential Measurements for Erectile Dysfunction

• External Penile Vacuum Constriction Devices

• Extracorporeal Shock Wave Therapy in the Treatment of Peyronie's Disease

• Internal Penile Prostheses

• Microalbumin Screening for Diabetic Nephropathy

• Nocturnal Penile Tumescence (NPT) Testing

• Pancreas/Pancreas-Kidney/Pancreatic Islet Cell Transplantation

• Pelvic Floor Stimulation

• Penile Brachial Index (PBI)

• Penile Revascularization

• Penile Venous Occlusive Procedure

• Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux (VUR)

• Pharmacological Response Test (PRT) for Erectile Dysfunction

• Positron Emission Tomography (PET) for Miscellaneous Applications

• Posterior Tibial Nerve Stimulation (PTNS) for Voiding Dysfunction

• Prostate Specific Antigen (PSA)

• Radioimmunoscintigraphy Imaging (Monoclonal Antibody Imaging) with Indium-111 Capromab Pendetide for Prostate Cancer

• Radiotherapy for Prostate Cancer

• Sacral Nerve Stimulation/Modulation for Pelvic Floor Dysfunction

• Saturation Biopsy for Diagnosis and Staging of Prostate Cancer

• Selective Internal Pudendal Arteriography (Angiography) for Erectile Dysfunction

• Sural Nerve Graft in Association with Radical Prostatectomy

• Transurethral Microwave Thermotherapy (TUMT)

• Transurethral Radiofrequency Needle Ablation of the Prostate (TUNA)

• Transvaginal and Transurethral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence

• Urethral Bulking Agents for Stress Urinary Incontinence

• Water-Induced Thermotherapy (WIT) for the Treatment of Benign Prostatic Hypertrophy

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