Bladder Instillation for Treatment of Interstitial Cystitis


	UM Guidelines

Ambulatory Care (AC)

BlueCross BlueShield of Tennessee developed this guideline to supplement the Milliman Care Guidelines®

BCBST modification effective February 22, 2008*

Clinical indications for bladder instillation for the treatment of interstitial cystitis exists when ALL the following are present:

Symptoms of interstitial cystitis, including ALL of the following:
- Urinary frequency during the day and/or night
- Urinary urgency
- Pain related to the bladder and/or pelvic area
An absence of other diseases that could cause the symptoms
Documentation of a hydrodistention cystoscopy that supports the diagnosis of interstitial cystitis

Goal Length of Stay – Ambulatory

Note: Typically performed as office procedures but can also be performed at home by Home Health.

References

American Academy of Family Physicians. (2001, October). Interstitial cystitis: urgency and frequency syndrome. Retrieved August 28, 2007 from http://www.aafp.org/afp/20011001/1199.pdf.
American Urology Association. UrologyHealth. (2004, January). Interstitial cystitis. Retrieved August 28, 2007 from http://urologyhealth.org/adult/index.cfm?cat=03&topic=210.
BlueCross BlueShield of Tennessee network physicians. September 2007.
Complete Guide to Medicare Coverage Issues [Computer software]. (2007, July). Dimethyl sulfoxide (DMSO) (NCD 230.12, p. 2186). St. Anthony Publishing.
Interstitial Cystitis Association. (2005, May). Interstitial cystitis. Retrieved August 28, 2007 from http://www.ichelp.com/TreatmentAndSelfHelp/TreatmentGuidelines.html.
National Institute of Diabetes and Digestive and Kidney Diseases. National Institutes of Health. (2005, May). Interstitial cystitis / painful bladder syndrome. Retrieved August 28, 2007 from http://kidney.niddk.nih.gov/kudiseases/pubs/pdf/interstitialcystitis.pdf.

* These guideline(s) have been revised from the Milliman USA Milliman Care Guidelines. The portions of the guideline(s) which have been revised are identified through the use of [insert: italic, boldface, underlined, etc. as appropriate] text, and Milliman USA has neither reviewed nor approved the modified material. Any statement to the contrary or association of the modified material with Milliman USA is strictly prohibited. This document has been classified as public information.

The above information only contains the modified portion of the Milliman Care Guideline. If you wish to view the complete Milliman Care Guideline, please contact Milliman USA.