CurrentAetnaPolicy 0679

Levator Syndrome Treatments

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Defines Aetna's coverage criteria for treatment of levator syndrome (proctalgia fugax/chronic anal pain syndrome) including high-voltage pulsed electrogalvanic stimulation and biofeedback, and lists interventions considered experimental/investigational. Applies to Aetna members and their treating providers.

Policy Summary

PayerAetna

PolicyLevator Syndrome Treatments

Policy CodePolicy 0679

Change TypeNo material clinical or coverage changes

Effective DateFeb 6, 2004

Last ReviewSep 19, 2023

Next Review DateJul 25, 2024

Key ActionObtain prior authorization and document failure of conservative therapies before requesting HVPGS or biofeedback.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

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CurrentAetnaPolicy 0679

Levator Syndrome Treatments

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Policy Summary

PayerAetna

PolicyLevator Syndrome Treatments

Policy CodePolicy 0679

Change TypeNo material clinical or coverage changes

Effective DateFeb 6, 2004

Last ReviewSep 19, 2023

Next Review DateJul 25, 2024

Key ActionObtain prior authorization and document failure of conservative therapies before requesting HVPGS or biofeedback.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3session limit (10 days)

2ICD-10 codes referenced

3experimental interventions

3administrative sections

Coverage Criteria

High-voltage pulsed electrogalvanic stimulation (HVPGS) - Medical necessity

Covered when ALL of the following are met:

HVPGS medical necessity criteria: 1) A neurological cause for the pain cannot be detected; AND 2) Member has failed prior conservative treatments (high-fiber diet; withdrawal of drugs that cause constipation or diarrhea; perineal strengthening exercises; rectal massage; warm baths; and drug therapy such as muscle relaxants, non-narcotic analgesics, and sedatives); AND 3) No underlying disease has been revealed by anorectal examination or by manometry, radiology, or endoscopy.

Session limit: More than three 60-minute HVPGS sessions administered over a 10-day period are not considered medically necessary.

Biofeedback

Covered when ALL of the following are met:

Biofeedback criteria: Biofeedback is considered medically necessary for members with refractory levator syndrome when the HVPGS criteria above are met (i.e., refractory after conservative therapy and no underlying disease detected).

Electrogalvanic stimulators intended for home use are considered experimental and investigational because they have not been demonstrated to be safe and effective for unsupervised use. The policy also identifies several interventions for levator syndrome as experimental and investigational, including botulinum toxin injections, injection of the pudendal nerve with corticosteroids or other agents, and sacral nerve stimulation.

When considering electrical stimulation therapies, providers should follow the policy’s selection criteria and coding guidance; CPT/HCPCS codes for in‑office electrical stimulation and biofeedback are addressed separately and certain procedure and supply codes for the listed interventions are explicitly not covered for this indication.

High‑voltage pulsed electrogalvanic stimulation (HVPGS) is considered experimental and investigational when the medical necessity criteria in this policy are not met. Coverage is contingent on documentation that a neurological cause cannot be detected, that prior conservative treatments have failed, and that no underlying disease has been identified by anorectal examination or by manometry, radiology, or endoscopy.

Coding

Covered CPT Codes (if selection criteria met)CPTCovered

97014	Application of a modality to one or more areas; electrical stimulation (unattended).
97032	Application of a modality to one or more areas; electrical stimulation, (manual), each 15 minutes.

CPT Codes Not Covered for Indications ListedCPTNot Covered

64430	Injection, anesthetic agent; pudendal nerve.
64630	Destruction by neurolytic agent; pudendal nerve.
64561	Percutaneous implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) including image guidance, if performed.
64575	Incision for implantation of neurostimulator electrode array; sacral nerve (transforaminal placement).

HCPCS Codes Covered if Selection Criteria MetHCPCSCovered

E0746	Electromyography (EMG), biofeedback device.
G0283	Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care.
E0745	Neuromuscular stimulator, electronic shock unit.

HCPCS/Codes Not Covered for Indications ListedHCPCSNot Covered

A4290	Sacral nerve stimulation test lead, each.
J0585	Botulinum toxin type A, per unit.
L8684	Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and bladder management, replacement.

ICD-10 Codes (covered if selection criteria met)ICD-10

K59.4	Anal spasm [proctalgia fugax].
K62.89	Other specified diseases of anus and rectum [chronic anal pain syndrome] [levator syndrome or chronic anal pain syndrome].

Provider Actions & Requirements

Prior Authorization

Prior authorization required for HVPGS/electrical stimulation

Prior authorization is required for high-voltage pulsed electrogalvanic stimulation and related covered electrical stimulation modalities; use the specific CPT/HCPCS codes listed in the policy when requesting authorization.

Note

No other prior authorization specified in this text

No additional prior authorization requirements are specified in the provided portion of the document.

Step Therapy

Document failure of conservative therapies prior to HVPGS/biofeedback

Document that the member has failed conservative therapies before HVPGS or biofeedback are initiated; conservative measures include high-fiber diet, withdrawal of offending drugs, perineal strengthening exercises, rectal massage, warm baths, and appropriate drug therapy.

Background

Levator syndrome (also called proctalgia fugax or chronic anal pain syndrome) is a benign disorder characterized by brief, episodic attacks of rectal discomfort or pain. Symptoms often occur at night or with straining and can vary in severity. Management begins with conservative measures (e.g., high‑fiber diet, withdrawal of offending medications, perineal exercises, rectal massage, warm baths, and symptomatic drug therapy), and targeted treatments such as HVPGS or biofeedback are reserved for refractory cases after evaluation rules out an underlying disease or a detectable neurological cause.

HVPGS has been used prophylactically to reduce attack frequency, with individual treatment sessions typically lasting 15–60 minutes and voltages titrated to patient tolerance; older studies report short‑term success rates ranging approximately from 65% to 91%, although long‑term effectiveness is variable.

Definitions

Levator syndrome (LS) — definition and alternate names

DefinitionA benign disorder characterized by brief, episodic attacks of rectal discomfort and pain of varying severity; attacks often occur suddenly (frequently at night) and typically last seconds to minutes.

Alternate namesAlso known as proctalgia fugax and chronic anal pain syndrome.

Typical featuresPain usually located in the upper anal canal just above the anal sphincter; precipitating factors include anxiety, stress, heat, cold, or fatigue.

Epidemiology/age courseCondition generally appears after puberty; frequency and severity of attacks tend to decrease after age 60.

High-voltage pulsed electrogalvanic stimulation (HVPGS) — technical description of the intervention

Technical description

Policy Summary

PayerAetna

PolicyLevator Syndrome Treatments

Policy CodePolicy 0679

Change TypeNo material clinical or coverage changes

Effective DateFeb 6, 2004

Last ReviewSep 19, 2023

Next Review DateJul 25, 2024

Key ActionObtain prior authorization and document failure of conservative therapies before requesting HVPGS or biofeedback.

SourceLink

On This Page

High-fiber diet
Withdrawal of drugs that cause constipation or diarrhea (examples listed in policy)
Perineal strengthening exercises; rectal massage; warm baths
Drug therapy such as muscle relaxants, non-narcotic analgesics, sedatives

Note

No step therapy specified in this text

No step therapy requirements are specified in the provided portion of the document.

Documentation Required

Required clinical documentation to support medical necessity

Clinical documentation must show no detectable neurological cause, failure of prior conservative treatments, and that no underlying disease was revealed by anorectal exam, manometry, radiology, or endoscopy.

Statement that a neurological cause for the pain cannot be detected
Records confirming prior conservative treatments were tried and failed (see list of therapies)
Results of anorectal examination, manometry, radiology, or endoscopy demonstrating no underlying disease

Note

Additional Aetna links/resources (no new documentation requirements)

This section lists Aetna resources (glossary, mobile app, FAQs, etc.) and related links; it does not add clinical documentation requirements beyond those in the policy.

Glossary, Aetna Mobile App, FAQs and other Aetna links are provided

Denial Risk

Must meet all selection criteria or treatment not covered

Failure to meet all required selection criteria (no detectable neurological cause; failed conservative treatments; no underlying disease on anorectal exam/manometry/radiology/endoscopy) will result in classification of HVPGS as experimental/investigational and it will not be covered.

Billing Rule

Session limit — maximum 3 × 60-minute HVPGS sessions per 10 days

More than three 60-minute HVPGS sessions administered over a 10-day period are not considered medically necessary and may be denied.

Maximum allowed: three 60-minute sessions within a 10-day period

Note

No additional denial triggers specified here

No specific denial triggers beyond the selection criteria and session limit are present in the provided portion of the document.

Anorectal electrical stimulation delivered via a sterile probe inserted into the anus using the negative electrode; pulse frequency typically set at about 80–120 cycles/second (Hz).

Voltage/intensityVoltage is started at 0, raised to patient discomfort threshold, then reduced to a comfortable level; may be gradually increased up to approximately 250–350 Volts as tolerated.

Session parametersTreatment sessions usually last between 15 and 60 minutes; HVPGS is often used prophylactically rather than during acute short attacks.

Use contextUsed for refractory levator syndrome when selection criteria are met; not employed for immediate symptom relief due to typically brief attacks.

Administrative/Additional Information — navigation and administrative items

Glossary and resourcesLinks to Aetna resources including Glossary, FAQs, Program Provisions, Privacy Center, and Site Map are provided for navigation and reference.

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