Covered without prior authorization (high confidence)
Documentation Required
If MR defecography is proposed, documentation must address the reasons for choosing MR (note: MR defecography is considered investigational for CPB-listed indications and MR-related CPTs are listed as not covered for CPB indications).
Documented chronic constipation as defined in the policy: presence of 2 or more of the following symptoms for at least 3 months: 'Lumpy and/or hard stools at least 1/4 of the time; or Sensation of incomplete evacuation at least 1/4 of the time; or Straining at defecation at least 1/4 of the time; or Two or fewer bowel movements per week.'
Results of anorectal manometry and rectal balloon expulsion test demonstrating negative or inconclusive findings (these tests must have been performed prior to defecography per policy).
Clinical documentation (history/physical, clinical notes, referral) showing suspicion of one or more of the specific causes of impaired defecation listed in the policy: anterior rectocele, enterocele, inappropriate contraction of the puborectalis muscle, or pelvic organ prolapse.
Key Coverage Criteria
Inappropriate contraction of the puborectalis muscle.
Pelvic organ prolapse.
Covered CPT code (if selection criteria are met): 74270 (Radiologic examination, colon; barium enema, with or without KUB).
ICD-10 codes covered if selection criteria are met:
K59.00 - K59.09 (Constipation) [policy notes: not covered for routine evaluation; covered only if selection criteria met].
K59.4 (Anal spasm [proctalgia fugax] [inappropriate contraction of the puborectalis muscle]).
Supporting ICD-10 diagnosis code(s) consistent with one of the policy-covered indications (see covered ICD-10 list).
Any imaging or prior test reports relied upon in the decision to order defecography (e.g., previous manometry, balloon expulsion, colon transit study) to document that selection criteria are met.