Medical Policy Update: Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux (VUR)

Effective April 13, 2018, the guidelines of our medical policy, Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux (VUR), will also be applied to claims for services provided to patients enrolled in Horizon Blue Cross Blue Shield of New Jersey Medicare Advantage (MA) plans. Presently the guidelines of this medical policy have not been applied to claims for services provided to MA members.

We encourage you to review this policy content in our Medical Policy Manual.

Based on the guidelines of our medical policy, Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux (VUR), and the submitted diagnosis code(s), claims for services provided on and after April 13, 2018 to members enrolled in Horizon BCBSNJ MA plans will be processed as noted below.

• Claims that include CPT^® code 52327 and/or HCPCS codes L8603, L8604, L8606 may pend while information required to determine medical appropriateness is requested and reviewed.

• CPT code 52327 and/or HCPCS code L8604 may be denied as a service not related to the submitted diagnosis code(s).

• HCPCS codes L8603 and/or L8606 may be denied as experimental/investigational non-covered services.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims on and after April 13, 2018 April 13, 2018.

CPT^® is a registered mark of the American Medical Association.