Urinary Incontinence (CPB 0223, reviewed 2026-07-16)

By July 16, 2026: Billing team must implement the following: (1) Require prior authorization for all urodynamic studies—verify documentation shows both symptoms AND physical findings of urinary incontinence/voiding dysfunction AND that conservative management has been attempted and failed; (2) For artificial urinary sphincter (AUS) implantation—confirm patient meets ONE of four specific indications (children with intractable UI refractory to behavioral/pharmacological therapy, 6+ months post-prostatectomy with failed conservative trials, failed bladder neck reconstruction with epispadias-exstrophy, or women with intractable UI who failed behavioral/pharmacological and other surgical treatments); (3) For sacral nerve stimulator permanent implantation (both urge incontinence and retention)—verify 6-month symptom duration with significant disability, documented failure of 2+ pharmacotherapies AND behavioral treatments after 12-week trial, AND successful temporary trial with 50% symptom reduction; (4) For bulking agent injections—deny claims after 3 failed treatment attempts; (5) For TVT/TOT/colposuspension/sling procedures—verify intractable stress UI with failed conservative management. Update billing software to flag these procedures for mandatory documentation review before submission. Failure to obtain prior authorization or verify medical necessity will result in claim denials. Medical reviewers and providers must document all required criteria on claim attachments.