Kidney Stones: Selected Interventions (CPB 0392, reviewed 2026-06-23)
Aetna's Clinical Policy Bulletin 0392 considers these kidney stone services experimental, investigational, or unproven: AEMC lithotripsy (Enhanced Lithotripsy System, Avvio Medical), CT or MRI for urolithiasis screening of asymptomatic persons, calcifying nanoparticles for assessing kidney stone risk, and genetic/molecular analysis for assessing kidney stone risk. Cystourethroscopy with vacuum aspiration kidney collecting systems, such as the Calyxo CVAC Aspiration System or the ClearPetra Suction Stone Extraction System, is considered investigational for urinary stone removal. CPT 0991T, CPT 72192 through 72197, ICD-10 N20.0 and ICD-10 Z87.442 are listed as not covered for the indications in the bulletin, and ICD-10 R82.991 through R82.998 are covered if selection criteria are met.