BlueCross BlueShield of Tennessee Medical Policy Manual

Genitourinary System

• Biofeedback and Neurofeedback

• Bulking Agents for the Treatment of Vesicoureteral Reflux (VUR) and Incontinence

• Cryosurgical Ablation of Solid Tumors

• Gene Expression Profile Analysis for Prostate Cancer Management

• Hemodialysis in the Home

• Lutetium Lu 177 Vipivotide Tetraxetan (Pluvicto®)

• MRI-Guided Focal Laser Ablation for Prostate Cancer

• Nerve Graft with Radical Prostatectomy

• Pancreas/Pancreas-Kidney/Pancreatic Islet Cell Transplantation

• Pelvic Floor Stimulation

• Percutaneous Arteriovenous Fistula (pAVF)

• Prostate Specific Antigen (PSA)

• Radiotherapy for Prostate Cancer

• Saturation Biopsy for Diagnosis and Staging of Prostate Cancer

• Transvaginal and Transurethral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence

• Treatment for Sexual Dysfunction in Males: Non-Pharmacologic

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