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UM Guidelines
Bladder Instillation for Treatment of Interstitial Cystitis

Ambulatory Care (AC)

BCBST last reviewed December 21, 2016*

Background

This procedure is performed to relieve the symptoms of interstitial cystitis, for which the cause and cure are not known. The procedure involves guiding a catheter up the urethra into the bladder. A measured amount of solution (e.g., dimethyl sulfoxide) is then passed through the catheter into the bladder, where it is retained for a specified amount of time (usually 15 minutes) before being expelled. Treatments with this procedure can be performed in the physician’s office or at home for individuals who are willing to catheterize themselves and do self-administration with physician approval.

Clinical Indications for Procedure

Bladder instillation may be indicated for ALL the following:

Goal Length of Stay - Ambulatory

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

References
  1. American Academy of Family Physicians. (2011, May). Interstitial cystitis/painful bladder syndrome. Retrieved August 26, 2013 from http://www.aafp.org/afp/2011/0515/p1175.html?printable=afp.
  2. American Urology Association. (2014, September). Diagnosis and treatment of interstitial cystitis /bladder pain syndrome. Retrieved August 30, 2016 from https://www.auanet.org/common/pdf/education/clinical‐guidance/IC‐Bladder‐Pain‐Syndrome‐Revised.pdf.
  3. BlueCross BlueShield of Tennessee network physicians. September ‐ December 2016.
  4. Centers for Medicare & Medicaid Services. CMS.gov. NCD for Dimethyl Sulfoxide (DMSO) (230.12). Retrieved August 30, 2016 from https://www.cms.gov/medicare‐coverage‐database/details/ncddetails.aspx?ncdid=149&ver=1.
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