Attachment C
Electromyography of Anal or Urethral Sphincter (CPT 51784 and 51785) IS CONSIDERED MEDICALLY NECESSARY FOR THE FOLLOWING INDICATIONS:
E08.43 Diabetes mellitus due to underlying condition with diabetic autonomic (poly)neuropathy
E09.43 Drug or chemical induced diabetes mellitus with neurological complications with diabetic autonomic (poly)neuropathy
E10.43 Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy
E11.43 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy
E13.43 Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy
G20.A1 Parkinson's disease without dyskinesia, without mention of fluctuations
G20.A2 Parkinson's disease without dyskinesia, with fluctuations
G20.B1 Parkinson's disease with dyskinesia, without mention of fluctuations
G20.B2 Parkinson's disease with dyskinesia, with fluctuations
G35 Multiple sclerosis
G83.4 Cauda equina syndrome
K59.01 Slow transit constipation
K59.02 Outlet dysfunction constipation
K59.04 Chronic idiopathic constipation
K59.09 Other constipation
K59.2 Neurogenic bowel, not elsewhere classified
K59.4 Anal spasm
M47.11 Other spondylosis with myelopathy, occipito-atlanto-axial region
M47.12 Other spondylosis with myelopathy, cervical region
M47.13 Other spondylosis with myelopathy, cervicothoracic region
M47.14 Other spondylosis with myelopathy, thoracic region
M47.15 Other spondylosis with myelopathy, thoracolumbar region
M47.16 Other spondylosis with myelopathy, lumbar region
M47.21 Other spondylosis with radiculopathy, occipito-atlanto-axial region
M47.22 Other spondylosis with radiculopathy, cervical region
M47.23 Other spondylosis with radiculopathy, cervicothoracic region
M47.24 Other spondylosis with radiculopathy, thoracic region
M47.25 Other spondylosis with radiculopathy, thoracolumbar region
M47.26 Other spondylosis with radiculopathy, lumbar region
M47.27 Other spondylosis with radiculopathy, lumbosacral region
M47.28 Other spondylosis with radiculopathy, sacral and sacrococcygeal region
M48.01 Spinal stenosis, occipito-atlanto-axial region
M48.02 Spinal stenosis, cervical region
M48.03 Spinal stenosis, cervicothoracic region
M48.04 Spinal stenosis, thoracic region
M48.05 Spinal stenosis, thoracolumbar region
M48.062 Spinal stenosis, lumbar region with neurogenic claudication
M48.07 Spinal stenosis, lumbosacral region
M48.08 Spinal stenosis, sacral and sacrococcygeal region
N31.0 Uninhibited neuropathic bladder, not elsewhere classified
N31.1 Reflex neuropathic bladder, not elsewhere classified
N31.2 Flaccid neuropathic bladder, not elsewhere classified
N31.8 Other neuromuscular dysfunction of bladder
N31.9 Neuromuscular dysfunction of bladder, unspecified
N36.42 Intrinsic sphincter deficiency (ISD)
N36.43 Combined hypermobility of urethra and intrinsic sphincter deficiency
N36.44 Muscular disorders of urethra
N36.8 Other specified disorders of urethra
N39.3 Stress incontinence (female) (male)
N39.41 Urge incontinence
N39.42 Incontinence without sensory awareness
N39.43 Post-void dribbling
N39.44 Nocturnal enuresis
N39.45 Continuous leakage
N39.46 Mixed incontinence
N39.490 Overflow incontinence
N39.491 Coital incontinence
N39.492 Postural (urinary) incontinence
N39.498 Other specified urinary incontinence
R15.0 Incomplete defecation
R15.1 Fecal smearing
R15.2 Fecal urgency
R15.9 Full incontinence of feces
R32 Unspecified urinary incontinence
R33.8 Other retention of urine
R33.9 Retention of urine, unspecified
R35.0 Frequency of micturition
R39.14 Feeling of incomplete bladder emptying
R39.15 Urgency of urination
R39.191 Need to immediately re-void
