CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence

Policy governing coverage of non-implantable pelvic floor electrical and magnetic stimulation as treatments for urinary and fecal incontinence for Blue Cross Blue Shield - Rhode Island members, with distinctions between Medicare Advantage and Commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence

Policy CodePolicy N/A

Change TypeNo material change noted

Effective DateApr 1, 2001

Next Review DateN/A

Key ActionVerify member benefits and, for Medicare Advantage members, document a failed 4-week trial of pelvic muscle exercises before electrical pelvic floor stimulation is covered.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Medicare AdvantageMA covered

Not coveredCommercial stance

Not requiredPrior auth

E0740 (MA only)HCPCS E0740

Coverage Criteria

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Medicare Advantage - Electrical PFS for Urinary Incontinence

Covered when ALL of the following are met:

Medicare Advantage coverage criteria: Non-implantable pelvic floor electrical stimulation is used for treatment of stress and/or urge urinary incontinence

cognitively intact patients

Prior conservative therapy: Documentation of a failed trial of pelvic muscle exercise (PME) training4 weeks

Defined as no clinically significant improvement after completing 4 weeks of an ordered PME plan

Medicare Advantage - Fecal Incontinence

Fecal incontinence stance: Pelvic floor electrical stimulation for fecal incontinence is considered not medically necessary

Insufficient peer-reviewed scientific literature

Commercial Products - Urinary and Fecal Incontinence

Commercial coverage stance: Pelvic floor electrical or magnetic stimulation for urinary and fecal incontinence is not covered and is a contract exclusion

Codes related to these services will be denied for Commercial Products

Electrical or magnetic pelvic floor stimulation (PFS) is evaluated separately for urinary and fecal incontinence. For fecal incontinence, the available evidence is insufficient: randomized trials of electrical PFS are few and inconclusive, and there are no randomized trials of magnetic PFS demonstrating clinical benefit. Therefore, electrical or magnetic PFS for fecal incontinence is considered not medically necessary due to insufficient peer‑reviewed scientific literature demonstrating effectiveness.

For urinary incontinence under Medicare Advantage, non‑implantable electrical PFS may be covered for treatment of stress and/or urge urinary incontinence in cognitively intact patients who have failed a documented trial of pelvic muscle exercise training (see coverage criteria). Magnetic (chair‑based) PFS is not supported by the evidence for fecal incontinence and is considered not medically necessary for that indication.

If a service is determined to be not medically necessary or is a non‑covered benefit under the member’s contract, providers should follow member‑specific benefit documents (subscriber agreement, member certificate, or employer agreement) to confirm coverage. These documents govern whether the service is payable and supersede the policy when applicable.

Pelvic floor electrical stimulation for fecal incontinence and extracorporeal pulsed magnetic stimulation for fecal incontinence are designated as not medically necessary because randomized controlled trials and systematic reviews do not provide sufficient evidence of net clinical benefit. The policy specifically notes a lack of sham‑controlled RCTs showing superiority of electrical stimulation and no available RCT evidence for magnetic PFS in fecal incontinence.

When a service is determined to be not medically necessary (or is a medically necessary service that is excluded under the member’s contract), providers may not charge the member for the service unless the provider has informed the member in advance and the member has agreed in writing to assume financial responsibility.

Coding

Advantage Plans - CPTCPTCovered

53899

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

Advantage Plans - modality codesCPTCovered

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

Advantage Plans - HCPCSHCPCSCovered

E0740

Incontinence treatment system, pelvic floor stimulator; monitor; sensor and/or trainer

Commercial Products - CPTCPT

53899

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

Commercial Products - modality codesCPTNot 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

Commercial Products - HCPCSHCPCSNot Covered

E0740

Incontinence treatment system, pelvic floor stimulator; monitor; sensor and/or trainer

Provider Actions & Billing Guidance

Prior Authorization

Prior authorization review is not required.

Note

Benefit Verification / Prior Authorization

Providers must verify member-specific benefits and determine whether prior authorization is required for the member's product. Contact BCBSRI provider call center or consult the member's subscriber agreement / certificate for benefit eligibility and coverage determinations.

Verify member benefits with BCBSRI prior to providing services
Obtain prior authorization when required per member-specific documents

Step Therapy

Step Therapy Requirement (Medicare Advantage)

For Medicare Advantage members, coverage of non‑implantable pelvic floor electrical stimulation requires documentation of a failed trial of pelvic muscle exercises (PME). A failed trial is defined as no clinically significant improvement in urinary continence after completing 4 weeks of an ordered PME program.

Step therapy: Documented failed trial of PME (4 weeks) required before electrical pelvic floor stimulation is covered for Medicare Advantage

Billing Rule

Member Financial Responsibility When Service Is Non‑Covered

If services are determined to be not medically necessary or are non‑covered benefits under the member's plan, do not charge the member unless you have informed the member in advance and obtained the member's written agreement to assume financial responsibility. Refer to your participation agreement for applicable provisions.

Do not bill the member for non‑covered services unless prior written agreement obtained
Check member certificate/subscriber agreement for benefit limitations

Denial Risk

Commercial Product Denials / Coding Guidance

For Commercial products: CPT codes 97014 and 97032 will be denied when billed for these pelvic floor stimulation services. HCPCS E0740 is not covered for Commercial Products. Use unlisted code 53899 for procedures without a specific CPT code (eg, magnetic stimulation for incontinence) where appropriate.

Not covered for Commercial: CPT 97014, CPT 97032
Not covered for Commercial: HCPCS E0740
Use CPT 53899 (Unlisted procedure, urinary system) when no specific code exists (eg, magnetic stimulation)

Definitions

inv-23: Pelvic floor stimulation (PFS) — definition and intent of treatment (electrical stimulation or extracorporeal pulsed magnetic stimulation)

DefinitionNon‑surgical stimulation of pelvic floor musculature using either non‑implantable electrical probes (vaginal or anal) connected to an external generator or extracorporeal pulsed magnetic stimulation (chair‑based magnet) to strengthen and exercise pelvic floor/periurethral muscles.

Intent of treatmentProvide neuromuscular electrical stimulation to strengthen and exercise pelvic floor musculature with the goal of improving urethral closure and continence.

Delivery methodsElectrical PFS: vaginal or anal probes connected to an external generator; Magnetic PFS: chair‑based system that does not require an internal electrode.

SettingsMay be administered in a physician's office or physical therapy facility; electrical PFS can include initial office training followed by home use with a rented or purchased device; magnetic PFS is typically given in office via specialized chair.

Parameter variabilityDevices and protocols vary by stimulation location, frequency (Hz), intensity/amplitude (mA), duty cycle, number and frequency of treatments, session length, and overall treatment period.

inv-24: Failed trial of pelvic muscle exercise (PME) — definition (no clinically significant improvement after 4 weeks of PME)

DefinitionNo clinically significant improvement in urinary continence after completing 4 weeks of an ordered plan of pelvic muscle exercises (PME).

Required duration4 weeks of a documented, ordered PME training program.

Context for useThis failed trial definition is required documentation for Medicare Advantage coverage of non‑implantable pelvic floor electrical stimulation for stress and/or urge urinary incontinence in cognitively intact patients.

OpenPayer

Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence

Coverage Criteria

Coding

Provider Actions & Billing Guidance

Background

Definitions