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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.
No material clinical or coverage changes in this revision.
Coverage Criteria
High-voltage pulsed electrogalvanic stimulation (HVPGS) - Medical necessity
Covered when ALL of the following are met:
Biofeedback
Covered when ALL of the following are met:
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
| 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). |
| 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 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.
No other prior authorization specified in this text
No additional prior authorization requirements are specified in the provided portion of the document.
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.
- 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
No step therapy specified in this text
No step therapy requirements are specified in the provided portion of the document.
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
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
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.
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
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.
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
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