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ACG
​
h.o.l.M.E.S.

Automated Clinical Guidelines

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Urology

Indicates Non-covered Service
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Ablative Therapy of Renal Lesions
Benign Prostatic Hypertrophy (BPH) Treatments
Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds
Circumcision - Medical indications
Collagenase clostridium histolyticum (Xiaflex ®)
Cryoablation of the Prostate
Anthem
Aetna
UHC
Aetna
Cigna
Humana
Anthem
Cigna
Humana
FloridaBlue
UHC
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Cryosurgery of Prostate
Enhanced Cystoscopy for Bladder Cancer
Extracorporeal Shock Wave Lithotripsy (ESWL)
Gender Reassignment Surgery
High Intensity Focused Ultrasound (HIFU)
Hydrocelectomy
Medicare
UHC
Incision & Drainage of Abscess of Skin, Subcutaneous & Accessory Structures
UHC
Aetna
Cigna
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Laser Ablation of the Prostate
Male Urethral Sling
Erectile Dysfunction Diagnosis & Treatment
Male Sexual Dysfunction Treatment: Nonpharmacologic
Multiparametric Magnetic Resonance Fusion Imaging Targeted Prostate Biopsy
Neurogenic Bladder Treatment
Nocturnal Enuresis Treatments
Medicare
Aetna
Aetna
Aetna
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urethrabulking.jpg
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Outpatient Cystourethroscopy
Penile Circumcision
Penile Prosthesis Implantation
Periurethral Injections of Bulking Agents
Vesicoureteral Reflux Treatment by Endoscopic Injection of Bulking Agents
Percutaneous Tibial Nerve Stimulation
Sacral Nerve Stimulation & Percutaneous Tibial Nerve Stimulation for Urinary & Fecal Incontinence; Urinary Retention
Anthem
Anthem
Anthem
Aetna
Anthem
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Posterior Tibial Nerve Stimulation (PTNS) for Voiding Dysfunction
Prostate Cancer Screening
Prostate Rectal Spacers
Prostate-Specific Antigen (PSA) Screening for Prostate Cancer
Prostate Biopsy
Prostate Biopsy using MRI Fusion Techniques
Prostate Saturation Biopsy
Medicaid
Aetna
Medicare
Cigna
Aetna
Anthem
FloridaBlue
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Prostate Surgical Interventions
Prostatectomy
Humana
Minimally Invasive Treatment for Benign Prostatic Hyperplasia Involving Prostatic Urethral Lift (Urolift)
Scrotal Ultrasonography
Surgical & Invasive Treatments for Overactive Bladder
Surgical & Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH)
UHC
Aetna
Medicare
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Posterior Tibial Nerve Stimulation (PTNS) for Voiding Dysfunction
Transrectal Ultrasound
Transurethral Waterjet Ablation of the Prostate
Treatment of Kidney Stones
UHC Outpatient Surgical Procedures - Site of Service Criteria: Male Genital System
UHC Outpatient Surgical Procedures - Site of Service Criteria: Urinary System
Ureteroscopy
Anthem
Medicare
UHC
Medicaid
Medicare
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Urethroplasty
UHC
Urinary Bladder Dysfunction Treatment
Urinary Incontinence Treatment
Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia (CMS771v3)
Urodynamics
Humana
Anthem
Aetna
Medicare
Uroflowmetric Evaluations
Variocele Treatment
Aetna
Medicaid
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Vasectomy Procedures
Water Vapor Thermal Therapy for LUTS/BPH
Whole Gland Cryoablation of Prostate Cancer
Aetna
Medicare
Indicates Non-covered Service
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cryoblationprostate.jpg
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Adjustable Continence Therapy
Artificial Intelligence-Based Software for Prostate Cancer Detection
Focal Laser Ablation for the Treatment of Prostate Cancer
Interstitial Motexafin Lutetium-mediated Photodynamic Therapy for Prostate Cancer
Nerve Graft after Prostatectomy
PCR Testing-UTI Panels
Pelvic Floor Stimulation as a Treatment of Incontinence
Cigna
Anthem
Anthem
Anthem
Cigna
Aetna
FloridaBlue
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Prostate Mapping Biopsy
Prostate Saturation Biopsy
Radiofrequency Ablation Renal Sympathetic Nerves
Transvaginal Radiofrequency Bladder Neck Suspension & Transurethral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence
Anthem
Anthem
Anthem
FloridaBlue
Cigna
Anthem
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Diagnosis & Treatment of Impotence (NCD 230.4)
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Incontinence Control Devices
(NCD 230.10)
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Sacral Nerve Stimulation for Urinary Incontinence (NCD 230.18)
Anthem
Cigna
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Perirectal Hydrogel Spacer
Anthem
FEP
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Injectable Bulking Agents for the Treatment of Urinary & Fecal Incontinence
FEP
FloridaBlue
FloridaBlue
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Temporary Prostatic Urethral Stents & Prostatic Urethral Lift
FloridaBlue
FloridaBlue
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