Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

·       Bed wetting or primary nocturnal enuresis (NE) refers to involuntary loss of urine during sleep in patients who have never stopped bedwetting. Primary NE usually resolves over time.

·       Bedwetting alarms are not covered.

1)    Nocturnal enuresis alarms are considered convenience items and are not covered.

2)    Desmopressin acetate (DDAVP) nasal spray or injection is not covered for enuresis.

3)    Desmopressin tablets are covered with no restrictions under the pharmacy benefit.

Codes Used In This BI:

S8270            Enuresis alarm

J2597             Desmopressin Acetate Injection

This policy applies to all QualChoice Health Plans, unless there is indication otherwise or a stated exclusion.  Consult individual plan sponsor Summary Plan Description (SPD) for self-insured plans.  In the event of a discrepancy between this policy and a self-insured customer’s SPD, the SPD will prevail.  State and federal mandates will be followed as they apply.