HCPCS L8605 is officially defined as "Injectable bulking agent, dextranomer/hyaluronic acid copolymer implant, anal canal, 1 ml, includes shipping and necessary supplies." HCPCS L8605 is referenced in 9 tracked payer policy changes from Health Net, Regence BlueShield, and 3 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for HCPCS L8605 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Health Net updated 22 medical policies in Q4 2019, including new policies for Antithrombin III treatment, implantable hypoglossal nerve stimulation, and video EEG monitoring. Key changes include lowered colorectal cancer screening age to 45, updated bariatric surgery criteria, and multiple billing code additions/removals across various specialties.
Health Net updated 25 medical policies for Q4 2019, affecting prior authorization requirements, billing codes, and coverage criteria across multiple specialties. Key changes include new prior auth requirements for antithrombin III, hypoglossal nerve stimulation, and video EEG, plus updated criteria for bariatric surgery, cardiac risk assessment, and various pain management procedures.
Health Net updated 25+ medical policies in Q4 2019 with significant changes to prior authorization requirements, coverage criteria, and billing codes across multiple specialties. Key changes include updated bariatric surgery criteria, new DNA stool screening age range (45-85), added prior authorization requirements for various procedures, and terminology updates for gender-affirming procedures.
New and emerging medical technologies and procedures named in the listed codes are considered investigational because the current scientific evidence is not yet sufficient to establish their impact on health outcomes. Contracts exclude investigational and cosmetic services or procedures from coverage. Providers may bill members for investigational or cosmetic services and are encouraged to tell members before rendering them that the members are likely to be financially responsible for the cost.
New and emerging medical technologies and procedures listed in this policy are considered investigational because current scientific evidence is not yet sufficient to establish their impact on health outcomes. The listed services include many CPT codes across imaging, implant, cardiac device, bone assessment, neurostimulation, and oncology algorithm analysis, several tied to named manufacturers. Contracts exclude from coverage services or procedures that are considered investigational, and providers may bill members for them.
Urethral bulking agents may be considered medically appropriate for urinary incontinence when they are FDA-approved and the indication criteria are met. Collagen implants are covered for stress incontinence due to urethral sphincter dysfunction that is unresponsive to conservative therapy, with a listed indication such as congenital or acquired sphincter weakness or biological female patients with abdominal leak point pressure of 100 cm H2O or less. Bulking agents are covered for stress incontinence due to intrinsic sphincter deficiency only in biological female patients unresponsive to conservative therapy. Urethral bulking agents are not medically necessary for urinary retention with overflow incontinence, ectopic ureter, neurogenic bladder dysfunction, urinary fistulas, or psychogenic incontinence. Perianal bulking agents for fecal incontinence are investigational.
Aetna's Clinical Policy Bulletin 0611 covers fecal incontinence. It considers anorectal manometry, anorectal ultrasonography, rectal sensory testing, biofeedback, bowel training, defecation programs, diet modification and pharmacotherapy medically necessary, and it lists anal sphincter repair, colostomy, the Acticon Neosphincter and sacral nerve stimulation as invasive treatments that need all diagnostic tests and a 3-month trial of two or more traditional treatments first, unless contraindicated. Several other treatments are listed as experimental, investigational or unproven, including anal slings, graciloplasty, injectable bulking agents, magnetic anal sphincter augmentation, posterior tibial nerve stimulation, topical estrogen, topical oxymetazoline, trans-anal radiofrequency therapy (Secca) and vaginal bowel control (Eclipse system).
Aetna covers sacral nerve stimulation for members with chronic fecal incontinence who have had an inadequate response to conservative treatment and have a weak but structurally intact anal sphincter. A temporary percutaneous peripheral nerve electrode is tested first, and a permanent implantable pulse generator is medically necessary only for members who have a 50% or greater improvement in incontinence symptoms from the temporary stimulation over a period of at least 48 hours. Anal sphincter repair, colostomy and the Acticon Neosphincter artificial bowel sphincter are medically necessary for severe fecal incontinence, defined as involuntary loss of solid or liquid stool on a weekly or more frequent basis, after all diagnostic tests and a 3-month trial of 2 or more traditional treatments, unless contraindicated, and after failure of or inability to use medical interventions. Anal slings, graciloplasty, injectable bulking agents, transanal radiofrequency therapy (Secca procedure), posterior tibial nerve stimulation, topical estrogen and several other listed treatments are considered experimental, investigational or unproven.
Carbon-coated spheres, calcium hydroxylapatite, polyacrylamide hydrogel, or polydimethylsiloxane may be considered medically necessary to treat stress urinary incontinence in men and women who have failed appropriate conservative therapy. Autologous cellular therapy, autologous fat, autologous ear chondrocytes, and any other periurethral bulking agent, including Teflon, are investigational for stress urinary incontinence. Periurethral bulking agents for urge urinary incontinence and perianal bulking agents for fecal incontinence are also investigational.
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