CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Non‑implantable Pelvic Floor Stimulation for Urinary and Fecal Incontinence — Coverage Criteria

Policy governing coverage of non‑implantable pelvic floor electrical and magnetic stimulation for treatment of urinary and fecal incontinence for BCBSRI members, with distinctions for Medicare Advantage and Commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyNon‑implantable Pelvic Floor Stimulation for Urinary and Fecal Incontinence — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionFor Medicare Advantage members, document a 4‑week trial of pelvic muscle exercises with no clinically significant improvement before considering non‑implantable electrical pelvic floor stimulation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CoveredMedicare electrical PFS

Not coveredMedicare magnetic PFS

ExcludedCommercial PFS

E0740HCPCS (Medicare)

53899

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Coverage Criteria

Medicare Advantage - Nonimplantable electrical PFS for urinary incontinence

Covered when ALL of the following are met

Medicare electrical PFS coverage criteria: Patient is a Medicare Advantage member; condition is stress and/or urge urinary incontinence; patient is cognitively intact; patient has failed a documented trial of pelvic muscle exercise (no clinically significant improvement after completing 4 weeks of an ordered PME plan)4 weeks

Coverage follows CMS National Coverage Determination for nonimplantable pelvic floor electrical stimulators.

Medicare Advantage - Magnetic PFS and fecal incontinence

Not covered

Medicare magnetic PFS and PFS for fecal incontinence: Pelvic floor magnetic stimulation with a non-implantable stimulator for treatment of stress and/or urge urinary incontinence is not covered; pelvic floor electrical or magnetic stimulation with a non-implantable stimulator for fecal incontinence is not covered

Evidence is insufficient to determine effects on health outcomes.

Commercial Products - Pelvic floor stimulation

Not covered / contract exclusion

Commercial exclusion: Pelvic floor electrical or magnetic stimulation with a non-implantable stimulator for urinary and fecal incontinence is not covered and is considered a contract exclusion for Commercial products

Benefits may vary by member; refer to Evidence of Coverage or Subscriber Agreement.

For Commercial products, pelvic floor electrical or magnetic stimulation with a non‑implantable stimulator for urinary and fecal incontinence is not covered and is considered a contract exclusion. Associated CPT and HCPCS codes used for these services will be denied when billed under Commercial benefits (see coding table for specific denied codes).

This policy is informational and does not replace member-specific benefit determinations. Coverage is governed by the member's subscriber agreement, member certificate, and employer agreement, which take precedence over this medical policy. For member-specific benefits or prior authorization requirements, contact the provider call center; documentation must support medical necessity per the member certificate and participation agreements. Members cannot be billed for services determined to be not medically necessary or non-covered unless they have been informed and provided written agreement in advance.

The evidence base does not consistently show clinical benefit for electrical or magnetic pelvic floor stimulation (PFS) across key populations. Systematic reviews and randomized controlled trials for electrical PFS in urinary incontinence have not demonstrated consistent improvements in symptoms, quality of life, or other patient‑important outcomes compared with placebo or conservative treatments; meta-analyses in men after prostatectomy also do not show significant benefit. For magnetic PFS, trials and a systematic review have been limited by small numbers, short follow‑up, methodological issues, and heterogeneity; evidence is therefore insufficient. For fecal incontinence, RCTs and reviews of electrical PFS have not shown superiority to controls, and no RCT evidence exists for magnetic PFS. Overall, the evidence is insufficient to determine net health outcomes for many uses of electrical or magnetic PFS.

Coding

Covered CPT Codes (Medicare Advantage - pulsed magnetic unlisted)CPT

53899

Unlisted procedure, urinary system (to be used for pulsed magnetic stimulation for the treatment of incontinence)

Covered modality CPT codes (when used for PFS, Medicare Advantage)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

Covered HCPCS (Medicare Advantage)HCPCSCovered

E0740

Nonimplanted pelvic floor electrical stimulator, complete system

Unlisted CPT for pulsed magnetic stimulation (Commercial/Fecal)CPT

53899

Unlisted procedure, urinary system (to be used for pulsed magnetic stimulation for the treatment of incontinence)

CPT codes denied when used for PFS (Commercial)CPTNot Covered

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

HCPCS denied (Commercial)HCPCSNot Covered

E0740

Nonimplanted pelvic floor electrical stimulator, complete system

inv-13: Pelvic muscle exercise trial duration — 4 weeks

Required duration4 weeks of an ordered pelvic muscle exercise (PME) plan

Definition of failed PME trialNo clinically significant improvement in urinary continence after completing 4 weeks

ApplicabilityRequired for Medicare Advantage coverage of non‑implantable pelvic floor electrical stimulators

Provider Actions & Operational Notes

Prior Authorization

PRIOR AUTHORIZATION

Not applicable

Note

Prior authorization and coverage verification

For member-specific benefits and coverage verification, contact the provider call center. Policy availability and coverage are subject to review and revision by BCBSRI; prior authorization requirements are determined by the member's subscriber agreement, employer agreement, and product design.

Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement.
For information on member-specific benefits, call the provider call center.
Coverage decisions are subject to BCBSRI review and may change without notice.

Background

Pelvic floor stimulation (PFS) refers to nonsurgical therapies intended to improve urinary or fecal continence by stimulating pelvic floor musculature or pudendal nerve pathways. PFS includes non‑implantable electrical stimulation delivered via vaginal or rectal probes connected to an external pulse generator, and extracorporeal magnetic (pulsed electromagnetic) stimulation delivered via a specialized chair. Treatment parameters (site, frequency, intensity, pulse characteristics, session duration, and setting) vary widely in the literature, and some devices have received FDA 510(k) clearance for urinary incontinence.

Definitions

inv-24: Pelvic floor stimulation (PFS) — Nonsurgical treatment involving electrical stimulation of pelvic floor muscles via probes connected to an external pulse generator or ext...

DefinitionNonsurgical treatment involving electrical stimulation of pelvic floor muscles via probes connected to an external pulse generator or extracorporeal pulsed magnetic stimulation administered with a specialized chair

ModalitiesIncludes electrical stimulation (vaginal or anal probes) and extracorporeal magnetic stimulation (specialized chair with embedded magnet)

Intended effectProposed to strengthen pelvic floor musculature or stimulate pudendal nerve pathways to improve urethral closure and promote reinnervation

SettingsElectrical PFS: office, physical therapy, or home (after training); Magnetic PFS: typically office-based

inv-25: Non‑implantable pelvic floor electrical stimulator — External device delivering neuromuscular electrical stimulation via vaginal or anal probes connected to an ex...

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyNon‑implantable Pelvic Floor Stimulation for Urinary and Fecal Incontinence — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2025

Next Review DateN/A

SourceLink

On This Page

Denial Risk

Commercial product denial triggers

Commercial products: Pelvic floor electrical or magnetic stimulation with a non‑implantable stimulator for urinary and fecal incontinence is not covered and is considered a contract exclusion. Billing for these services under Commercial products may be denied.

Commercial denial applies to non‑implanted electrical stimulators and pulsed magnetic stimulation.
Providers should not bill members for covered services denied as non‑covered without documented member agreement (see Member agreement and billing risk).

Billing Rule

Medicare coding/coverage guidance

For Medicare Advantage plans there are specific coding and coverage rules: use HCPCS E0740 for nonimplanted pelvic floor electrical stimulator (complete system) and CPT codes 97014 and 97032 when appropriately used for pelvic floor electrical stimulation services. Use CPT 53899 (Unlisted procedure, urinary system) for pulsed magnetic stimulation when no specific CPT exists.

Covered for Medicare Advantage when criteria met: E0740, 97014, 97032, and 53899 (unlisted) as applicable.
Commercial products: these CPT/HCPCS codes are not covered when used for pelvic floor stimulation and will be denied.

Documentation Required

Required documentation for Medicare Advantage electrical PFS

For Medicare Advantage coverage of electrical pelvic floor stimulation, documentation must include: clinical indication, cognitive status (cognitively intact), documentation of a supervised and ordered 4‑week trial of pelvic muscle exercises (PME) with no clinically significant improvement, details of the PME plan (duration, frequency, exercises), and records of prior conservative therapies attempted.

Documentation of failed trial of PME (4 weeks) is required: no clinically significant improvement after completing the ordered PME plan.
Document cognitive status and clinical diagnosis supporting use (stress and/or urge urinary incontinence).
Record device used, treatment parameters, and clinical response.

Step Therapy

PME trial requirement

Medicare Advantage requires a documented trial of pelvic muscle exercises (PME) training of at least 4 weeks with lack of clinically significant improvement before pelvic floor electrical stimulation will be covered.

A failed trial of PME is defined as no clinically significant improvement in urinary continence after completing 4 weeks of an ordered plan of pelvic muscle exercises designed to increase periurethral muscle strength.

Note

Conservative therapy context

Conservative therapies (behavioral therapy, pelvic floor muscle training/biofeedback, supervised PME) are the recommended initial approach per clinical guidelines (AUA/SUFU, NICE, Cochrane). Electrical or magnetic stimulation is considered in the context of failed conservative therapy.

Clinical guidelines emphasize pelvic floor muscle training and behavioral interventions as first‑line therapy.
Systematic reviews (Cochrane, AHRQ) discuss limited and mixed evidence for non‑implanted electrical/magnetic stimulation; consider these modalities only after conservative therapies have been tried.

Device descriptionExternal device delivering neuromuscular electrical stimulation to pelvic floor musculature via vaginal or anal probes connected to an external pulse generator

FDA-cleared examplesMyoTrac Infiniti, ApexM, Pathway CTS 2000, InCare PRS, itouch Sure Pelvic Floor Exerciser (per document)

Use and settingUsed in-office, in physical therapy, or at home after initial training; parameters (frequency, intensity, pulse duration) vary by clinical diagnosis

inv-26: Electrical stimulation / pelvic floor electrical stimulation — Non-implanted electrical stimulation applied to pelvic floor muscles or anal sphincter to improve continence...

DefinitionNon-implanted electrical stimulation applied to pelvic floor muscles or anal sphincter to improve continence, often delivered via vaginal or anal probes and external pulse generators

Variable parametersStimulus frequency, intensity (mA), pulse duration, treatments per day/week, session length, and overall treatment period vary widely

Clinical intentAimed at strengthening/exercising pelvic floor musculature for stress and/or urge urinary incontinence

inv-27: Magnetic (electromagnetic) stimulation / extracorporeal magnetic innervation — Noninvasive electromagnetic stimulation of pelvic floor musculature evaluated for stress and urgency urinary incontinence as an alternati...

DefinitionNoninvasive electromagnetic stimulation of pelvic floor musculature administered with a specialized chair (patients sit fully clothed)

Mechanism and deliveryExtracorporeal pulsed magnetic fields generated from a chair seat with a separate power unit to stimulate pelvic floor muscles without internal electrodes

Clinical evaluationEvaluated as an alternative to electrical stimulation for stress and urgency urinary incontinence; magnetic systems previously cleared (eg, NeoControl)