Defecography (CPB 0718, reviewed 2025-10-14)

By October 14, 2025: Billing team must implement prior authorization requirements for defecography claims (CPT 74270) and MR defecography (CPT 72195, 72196, 72197) in the billing system. Require prior auth submission to include: (1) documentation of chronic constipation per policy definition (2+ symptoms for 3+ months), (2) results of anorectal manometry AND rectal balloon expulsion testing showing negative or inconclusive findings, and (3) clinical suspicion of anterior rectocele, enterocele, puborectalis dysfunction, or pelvic prolapse. Reject claims for routine constipation evaluation (K59.00-K59.09 used alone) and pre-operative LARS prediction (Z01.818). For MR defecography, only approve when conventional defecography has been inconclusive and obstructed defecation syndrome or functional defecation disorders documented. Update encounter templates and provider guidance documents. Flag for denial any claims without complete clinical justification per criteria. Notify providers in writing of coverage restrictions effective date.