CurrentBlue Cross Blue Shield - MassachusettsPolicy 470

Pelvic Floor Stimulation for Urinary and Fecal Incontinence

This policy governs the coverage stance and utilization management (including prior authorization) for electrical and magnetic pelvic floor stimulation as treatments for urinary and fecal incontinence for Blue Cross Blue Shield - Massachusetts members.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyPelvic Floor Stimulation for Urinary and Fecal Incontinence

Policy CodePolicy 470

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain precertification/preauthorization when the procedure is performed inpatient.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

investigationalUrinary incontinence (commercial)

investigationalFecal incontinence (commercial)

required (inpatient)Precertification

E0740HCPCS listed

31References

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Coverage Determination and Criteria

Overall coverage determination

Covered when ALL of the following are met:

Primary policy stance: Electrical or magnetic stimulation of the pelvic floor muscles (pelvic floor stimulation) as a treatment for urinary incontinence is investigational; electrical or magnetic stimulation of the pelvic floor muscles as a treatment for fecal incontinence is investigational.

Statement applies to Commercial members (Managed Care, PPO, and Indemnity) as presented.

Outpatient pelvic floor stimulation is not a covered service for the specified commercial products. Specifically, when performed in the outpatient setting this policy states the service is not covered for Commercial PPO and Indemnity products.

This policy cites the Centers for Medicare & Medicaid Services National Coverage Determinations (see CMS Manual System: Pub 100-03 Medicare National Coverage Determinations; Transmittal 48). Consult the CMS NCD materials directly for any CMS-stated exclusions or non-coverage that may affect coverage determinations.

Coding and Billing

Investigational HCPCS listedHCPCSNot Covered

E0740

Non-implanted pelvic floor electrical stimulator, complete system

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization / precertification IS REQUIRED for services described in this policy when the procedure is performed inpatient. Review member contract benefits for product-specific requirements.

Inpatient procedures: prior authorization required for all products when performed inpatient.
Outpatient procedures: certain commercial products (Commercial PPO and Indemnity) — outpatient pelvic floor stimulation as described in this policy is not a covered service.
CMS guidance: Medicare National Coverage Determinations may affect coverage and authorization decisions. See CMS NCD guidance (Pub 100-03, Transmittal 48) for relevant NCD details.

Billing Rule

Coding and Documentation

Providers must report all services using current, industry-standard procedure, revenue, and diagnosis codes, including appropriate modifiers. Accurate coding and documentation support coverage determinations and claim adjudication.

Background

Pelvic floor stimulation (PFS) uses either electrical or extracorporeal magnetic pulses to activate the pelvic floor musculature and the pudendal nerve with the goal of improving urethral closure and promoting reinnervation of partially denervated muscle. Electrical PFS may be delivered via vaginal or rectal probes or as a home device that requires an internal electrode, whereas magnetic PFS is delivered externally (for example, via a treatment chair) and does not require an internal electrode.

Definitions and Key Terms

Pelvic floor stimulation definition

TermPelvic floor stimulation (PFS)

DefinitionInvolves electrical stimulation of pelvic floor muscles using either an internal probe wired to a controlling device or extracorporeal electromagnetic (magnetic) pulses to stimulate the pudendal nerve and pelvic musculature.

Delivery methodsElectrical PFS: vaginal or rectal probes; Magnetic (extracorporeal) PFS: patient sits fully clothed on a specialized chair with embedded magnet — no internal electrode required.

Physiologic rationaleMay improve urethral closure and promote reinnervation of partially denervated urethral and pelvic floor musculature.

HCPCS E0740 definition — non-implanted pelvic floor electrical stimulator, complete system

HCPCS Code

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyPelvic Floor Stimulation for Urinary and Fecal Incontinence

Policy CodePolicy 470

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain precertification/preauthorization when the procedure is performed inpatient.

SourceLink

On This Page

Use up-to-date CPT, HCPCS (including E0740 where applicable), and ICD-10 codes.
Inclusion of a code in this policy does not guarantee member coverage or reimbursement; verify member contract benefits at time of service.

Documentation Required

Supportive Evidence to Include in Documentation

Include supportive clinical evidence and guideline-based documentation in the prior authorization request and the medical record to justify medical necessity.

Document prior conservative therapies tried and failed (e.g., pelvic floor rehabilitation, biofeedback, behavioral therapies) and duration of each.
Provide results of relevant diagnostic testing and validated symptom scores where available.
Cite pertinent guideline recommendations or clinical trial evidence supporting the requested service.

DescriptionNon-implanted pelvic floor electrical stimulator, complete system.

Policy noteListed in coding as the non-implanted pelvic floor electrical stimulator complete system; inclusion does not imply coverage — the policy lists pelvic floor stimulation as investigational for commercial members.

electrical stimulation / electromagnetic/magnetic stimulation definition

TermElectrical stimulation / Electromagnetic (magnetic) stimulation

DefinitionTherapies using electrical pulses (delivered via internal probes) or extracorporeal magnetic pulses (delivered via a specialized chair) to stimulate pelvic floor or anal sphincter muscles and pudendal nerve with the aim of reducing urinary or fecal incontinence symptoms.

Clinical variationsMethods vary by stimulation location (vaginal, rectal), pulse frequency, intensity/amplitude, pulse duration, duty cycle, number and frequency of treatment sessions.

Evidence contextBoth electrical and magnetic modalities have been investigated in randomized trials and systematic reviews cited in the policy references.