CurrentBaylor Scott & White Health PlanPolicy 052

Incontinence Treatment (Urinary and Fecal)

Defines medical coverage, prior authorization, and medical necessity criteria for treatments of urinary and fecal incontinence (including biofeedback, sacral nerve stimulation, posterior tibial nerve stimulation, and related interventions) for Baylor Scott & White Health Plan members.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyIncontinence Treatment (Urinary and Fecal)

Policy CodePolicy 052

Change TypeNo material changes

Effective Date04/01/2025

Next Review Date03/10/2026

Key ActionObtain prior authorization for sacral nerve stimulator procedures per plan EOC/SPD.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12Initial PTNS sessions

50%PTNS response threshold

12 wksPTNS response window

052Policy

03/10/2026Next review

Coverage Criteria for Incontinence Treatments

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Biofeedback for urinary incontinence

Covered only if contract provides coverage and when part of physical therapy instruction:

Biofeedback coverage conditions: Biofeedback is not itself a treatment but a tool to teach pelvic muscle (Kegel) exercises; when the member's contract provides coverage, prior authorization is not required and physical therapy that includes instruction in pelvic muscle exercises may be covered when medically appropriate. Further biofeedback therapy after proficiency is achieved is not covered.

Transurethral RF therapy (Renessa)

Coverage stance

Renessa: Transurethral RF Therapy (Renessa Procedure) is considered experimental, investigational and/or unproven and therefore NOT medically necessary for treatment of stress urinary incontinence.

Posterior Tibial Nerve Stimulation (PTNS)

Covered when ALL of the following are met

Initial PTNS series: An initial treatment plan of up to 12 weekly, 30-minute sessions is considered medically necessary.12 sessions

Indication: PTNS may be considered medically necessary for the treatment of medically diagnosed overactive bladder which has failed standard pharmacotherapy.

Response requirement and continuation: Patients must report improvement in symptoms within 12 weeks (12 sessions) for continued coverage. Treatment beyond the initial 12 sessions may be allowed every 1 to 2 months for up to 12 months only if documentation shows a 50% decrease in symptoms as evidenced by a daily uro-log/voiding diary and improved quality of life. Treatments after 12 months are considered experimental/investigational.50% symptom decrease

Document objective evidence (voiding diary/uro-log) to support continuation.

Fecal incontinence interventions

Coverage stance

SNS for fecal incontinence: Sacral Nerve Stimulator (SNS) for fecal incontinence: use InterQual as directed to determine medical necessity.

Solesta (injectable bulking agent) is considered experimental and investigational and therefore NOT medically necessary for treatment of fecal incontinence.

Botox for fecal incontinence is considered experimental and investigational and therefore NOT medically necessary.

Bedwetting alarms (enuresis alarms) are commercially available without a prescription and therefore are not covered by the health plan.

The source material in these sections is limited to references and organizational notes; no specific exclusions beyond those already stated are explicitly listed in these chunks.

The policy identifies several interventions and gives coverage stances: Transurethral RF Therapy (Renessa) is considered experimental, investigational and/or unproven and therefore not medically necessary for treatment of stress urinary incontinence; for fecal incontinence, Solesta (injectable bulking agent) and Botox are listed as experimental and investigational and not medically necessary. Sacral nerve stimulation is referenced for fecal incontinence with instruction to use InterQual to determine medical necessity.

The referenced chunks contain study citations, device manuals, and bibliographic material but do not include explicit additional statements labeling specific procedures as not medically necessary beyond those already cited elsewhere in the policy.

Relevant Billing and Diagnosis Codes

Covered CPT Codes (examples)CPT

53445	Insertion of tandem cuff (dual cuff)
64561	Percutaneous implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) including image guidance
64566	Posterior tibial neurostimulation, percutaneous needle electrode, single treatment; includes programming
64581	Incision for implantation of neurostimulator electrode array; sacral nerve (transforaminal placement)
64585	Revision or removal of peripheral neurostimulator electrode array
64590	Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling
64595	Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver
95970	Electronic analysis of implanted neurostimulator pulse generator system; without reprogramming
95971	Electronic analysis of implanted neurostimulator pulse generator system; with programming
95972	Electronic analysis of implanted neurostimulator pulse generator system; complex

CPT Codes NOT CoveredCPTNot Covered

53860

Transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence

HCPCS Codes (examples)HCPCS

A4290	Sacral nerve stimulation test lead, each
C1767	Generator, neurostimulator (implantable), nonrechargeable
E0745	Neuromuscular stimulator; electronic shock unit
L8679	Implantable neurostimulator, pulse generator, any type
L8681	Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only
L8682	Implantable neurostimulator radiofrequency receiver
L8683	Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver
L8684	Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and bladder management, replacement
L8689	External recharging system for battery (internal) for use with implantable neurostimulator, replacement only

ICD-10 Codes (examples)ICD-10

N31.0	Neuropathic bladder, unspecified (example listed)
N39.3	Stress incontinence
N39.41	Urge incontinence
N39.46	Mixed incontinence
R15.X	Incontinence of feces
R32	Unspecified urinary incontinence
R33.0	Retention of urine
R35.0	Frequency of micturition

PTNS symptom improvement threshold

PTNS continuation requirementDocumentation must show a 50% decrease in symptoms as evidenced by a daily uro-log/voiding diary to allow treatment beyond the initial 12 weekly sessions.

Initial treatment courseAn initial plan of up to 12 weekly, 30-minute PTNS sessions is considered medically necessary.

Time window to demonstrate responsePatients must report improvement within 12 weeks (12 sessions) for continued coverage.

Extended treatment frequency and durationIf 50% symptom reduction is documented, treatment beyond the initial series may continue every 1–2 months for up to 12 months.

Evidence source for measurementSymptom improvement must be evidenced by a daily uro-log (record of bladder events, voiding diary).

Provider Requirements, Authorizations, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for Sacral Nerve Stimulator. See the plan EOC/SPD for coverage details and to confirm benefits; absence of prior authorization may result in denial of the request.

Applies to requests for Sacral Nerve Stimulation (SNS) implants and related services.
Confirm member-specific benefit coverage in the Evidence of Coverage (EOC) or Summary Plan Description (SPD) before authorization.

Note

No Explicit Additional Authorization Triggers Specified

There are no explicit prior authorization, prior authorization triggers, or denial-trigger rules detailed elsewhere in this section beyond the SNS requirement above. Providers should follow submitted plan EOC/SPD guidance and payer authorization workflows when submitting requests.

No additional prior authorization triggers are specified in this document portion.
If plan documents or line-of-business rules (Medicare/Medicaid/Commercial) impose further authorization requirements, follow those specific instructions.

Step Therapy

Step Therapy Requirements Not Specified

Step therapy requirements are not specified in these chunks. For Posterior Tibial Nerve Stimulation (PTNS), the policy states PTNS is considered only after failure of standard pharmacotherapy; however, no formal step therapy (e.g., mandated trials or medication lists) or automated step edits are defined in this section.

PTNS: medically necessary only after failure of standard pharmacotherapy for overactive bladder, with documentation of symptom response to continue therapy.
No plan-level step therapy protocol (drug sequencing or approval conditions) is provided in this section — check member's plan documents or prior authorization rules for any step edits.

Documentation Required

Documentation Required for Continuation

Documentation requirements for continuation of PTNS and for other therapies: maintain objective evidence of clinical improvement to support continued coverage and reauthorization.

For PTNS continuation: documentation must show symptom improvement within 12 weeks (12 sessions) and for ongoing treatment a ≥50% decrease in symptoms demonstrated by a voiding diary/uro-log and improved quality of life.
Retain and submit clinical notes, voiding diaries, and any validated symptom scores when requesting continuation or reauthorization.

Note

Supporting References Available

Supporting clinical references (studies, device manuals) are cited in the full policy and may be used to substantiate medical necessity determinations; providers may include relevant literature with authorization requests as needed.

References include randomized trials and device manuals for sacral nerve stimulation and studies supporting PTNS efficacy.
Include pertinent study citations or device information when rationale for medical necessity depends on published evidence.

Background and Scope

Urinary incontinence encompasses several clinical types—stress, urge, overflow, and mixed—and management spans conservative to invasive options. First-line and conservative treatments include pelvic muscle training (Kegel exercises), behavioral therapies, and physical therapy; biofeedback is described as a tool to teach pelvic muscle exercises and may be covered only if the member contract provides coverage and while instruction/proficiency is being achieved. Pharmacotherapy is an important treatment option for overactive bladder; posterior tibial nerve stimulation (PTNS) is considered when standard pharmacotherapy has failed, with an initial series of up to 12 weekly, 30‑minute sessions considered medically necessary and continuation allowed only with documented symptom improvement (see policy thresholds). More invasive options include neuromodulation such as sacral nerve stimulation and surgical interventions; for fecal incontinence, options discussed include sacral nerve stimulation and injectable bulking agents, though some injectable agents and Botox are considered experimental/investigational in this policy.

Definitions and Key Terms

Types of urinary incontinence

Stress incontinenceUrine loss that occurs with an increase in abdominal pressure, often due to urethral hypermobility.

Urge incontinenceInvoluntary urine loss related to detrusor overactivity (sudden, compelling need to void).

Overflow incontinenceDribbling or leaking associated with incomplete bladder emptying and urinary retention.

Mixed incontinenceCombination of stress and urge incontinence symptoms occurring together.

Sacral nerve stimulation — overview

DefinitionApplication of mild electrical pulses to the sacral nerves via a surgically implanted neuromodulation system to modulate bladder, bowel, sphincter, and pelvic floor function.

Common systemInterStim Therapy System (Medtronic) is an example of an implantable sacral neuromodulation device referenced in the policy.

Clinical useUsed to treat fecal incontinence by modulating sacral nerve activity that influences bladder, bowel, urinary and anal sphincter function.

Sacral nerve stimulation (SNS) — evidence and device references

Clinical evidence summaryMultiple randomized, controlled and long-term studies report efficacy of sacral nerve stimulation (SNS) for fecal incontinence, including multicenter double-blind crossover and long-term follow-up studies.

Device manuals and manufacturer referencesMedtronic InterStim therapy and implant manuals (Model 3023, 3058) and Indications/Safety documents are cited as supporting references.

Study outcomesPublished reports include improved continence and quality-of-life outcomes and comparisons showing SNS superior to optimal medical therapy in severe FI in randomized trials.

Injectable bulking agents for fecal incontinence

Agent exampleDextranomer in stabilized hyaluronic acid (NASHA Dx / Solesta) is an injectable bulking agent referenced for treatment of fecal incontinence.

PurposeInjected to bulk the anal canal to reduce episodes of fecal incontinence.

Evidence notesRandomized, sham-controlled and open-label multicenter studies of dextranomer/stabilized hyaluronic acid for FI are cited (e.g., Graf et al., Lancet; NASHA Dx studies).

Policy stanceSolesta (injectable bulking agent) is considered experimental and investigational per the policy criteria sets.

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