Highmark Guideline - Kidney Stones & Hydronephrosis Management
Highmark POC Policy Set · effective 2026-01-01 · version v1
Metadata
Doc IDguideline::highmark::kidney_stones_hydronephrosis_v1
PayerHighmark
Payer Slughighmark
Topickidney stones hydronephrosis
Document Typepayer_guideline
Chunks5
Covered ICD Codes (8)
N20.0
N21.0
N13.1
N13.2
N13.30
R10.9
R10.30
N17.9
Procedure Keywords (9)
ureteroscopy with laser lithotripsy
URS LL
ureteral stent placement
ureteral stent exchange
bilateral ureteral stent
extracorporeal shock wave lithotripsy (ESWL)
percutaneous nephrolithotomy (PCNL)
retrograde pyelogram
nephroureterostomy
Guideline Chunks (5)
Each chunk has its own embedding and is independently retrievable
guideline::highmark::kidney_stones_hydronephrosis_v1#chunk0
Coverage may be considered when ureteral stent placement, exchange, or stone-removal procedures are medically necessary to relieve obstruction, preserve renal function, or manage symptomatic nephrolithiasis.
guideline::highmark::kidney_stones_hydronephrosis_v1#chunk1
1. Documented kidney stone (ICD N20.0) or bladder stone (ICD N21.0) confirmed on imaging.
2. Hydronephrosis (ICD N13.1, N13.2, N13.30) confirmed by ultrasound, CT, or MAG3 renal scan.
3. Recurrent UTI (ICD N39.0) associated with obstruction or stenting.
4. Acute renal failure (ICD N17.9) related to obstructive uropathy.
5. Flank pain or lower abdominal pain (ICD R10.9, R10.30) with imaging evidence of obstruction.
6. Prior ureteral stent placement requiring scheduled exchange to prevent encrustation, infection, or obstruction.
guideline::highmark::kidney_stones_hydronephrosis_v1#chunk2
1. Imaging report (CT, ultrasound, MAG3) confirming stone or obstruction.
2. Stone size, location, and laterality.
3. Renal function panel (creatinine trend, eGFR).
4. Prior surgical or stent history.
5. Symptom timeline including pain, infection, or hematuria.
6. Documentation of conservative management attempts for stones below intervention threshold.
guideline::highmark::kidney_stones_hydronephrosis_v1#chunk3
1. Stone size below threshold for surgical intervention without obstructive symptoms.
2. Missing imaging confirmation of obstruction.
3. No documented evidence of prior conservative management.
4. Renal function preserved without symptoms requiring intervention.
5. Requested intervention not aligned with documented stone location or size.
guideline::highmark::kidney_stones_hydronephrosis_v1#chunk4
Likely eligible when imaging confirms obstruction or stone size meets surgical threshold with symptoms, prior conservative management is documented, and renal function or infection history supports intervention.
Manual review when imaging is borderline or symptoms are intermittent without renal compromise.
Likely not eligible when no imaging evidence of obstruction is provided or when conservative management has not been attempted for non-obstructing stones.