Payer Policies for Renessa as a Covered Service

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Medicare Carrier Policies

MAC: Noridian
Policy: CPT 0193T and Renessa

First Coast Service Options (MAC Part B)
POTENTIAL COVEARAGE DETERMINED ON CASE BY CASE BASIS
Florida, Puerto Rico, Virgin Islands

• LCD # L29288 (Florida)
• LCD # L29398 (Puerto Rico, Virgin Islands)
• Effective June 30, 2009, FCSO will no longer list 0193T as a code in the Category III non-covered services list.
• FSCO is not issuing a positive coverage statement at this time regarding the Renessa® procedure.
• To provide an option for those physicians who are appropriately trained in treating women with stress urinary incontinence (SUI) and who are appropriately trained in performing the Renessa® procedure, FSCO will be looking at claims for the Renessa® procedure on an individual case by case basis.
• FCSO expects that providers submitting claims for Renessa® are providing the services within the FDA approved guidelines and in accordance with the indications supported by peer-reviewed literature which limits its use to moderate to severe stress urinary incontinence (SUI) in females (Dx code 625.6).
• Source: June 2009 The FCSO Medicare B Update! Pg. 31

Private Payer Policies

Private Payer: Aetna
Policy: 0223 Urinary Incontinence Treatments

Other Payers That Have Coverage Policies on Renessa

Michigan: Priority Health
Florida: Avmed, HealthFirst