CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence

This policy defines coverage and coding for non-implantable pelvic floor electrical and magnetic stimulation as treatments for urinary and fecal incontinence for Blue Cross & Blue Shield of Rhode Island products, distinguishing Medicare Advantage Plans from 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 changes

Effective DateApr 1, 2001

Next Review DateN/A

Key ActionFor Medicare Advantage members, document a failed trial of pelvic muscle exercises (4 weeks of PME) and cognitive intactness before covering pelvic floor electrical stimulation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Advantage onlyMedicare coverage

Not coveredCommercial stance

Not coveredFecal incontinence

53899Unlisted CPT

~30

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Coverage Criteria

Medicare Advantage - Covered Indications

Covered when ALL of the following are met for Medicare Advantage members:

Medicare Advantage coverage criteria: Non-implantable pelvic floor electrical stimulation is used.

Stimulation is generally delivered by vaginal or anal probes connected to an external generator; parameters vary by diagnosis.

Medicare Advantage coverage criteria: Indication is stress and/or urge urinary incontinence.

Medicare Advantage coverage criteria: Patient is cognitively intact.

Medicare Advantage coverage criteria: Patient has failed a documented trial of pelvic muscle exercise (PME) training, defined as no clinically significant improvement in urinary continence after completing 4 weeks of an ordered PME plan.

A failed trial of PME is defined in the Medicare NCD as no clinically significant improvement after 4 weeks of an ordered PME program.

Commercial Products - Not Covered

Commercial Products:

Commercial exclusion: Pelvic floor electrical or magnetic stimulation for urinary and fecal incontinence is not covered and is considered a contract exclusion for Commercial Products.

Related CPT/HCPCS codes will be denied when used for these services.

Fecal Incontinence - Not Covered / Not Medically Necessary

Fecal incontinence:

Fecal incontinence stance: Electrical or magnetic pelvic floor stimulation for fecal incontinence is not covered / not medically necessary due to insufficient evidence.

Medicare Advantage specifically states electrical PFS for fecal incontinence is not covered; no studies were identified for magnetic PFS for fecal incontinence.

For Commercial Products, pelvic floor electrical or magnetic stimulation for urinary and fecal incontinence is a contract exclusion and therefore not covered. As a result, associated CPT and HCPCS codes used for these services will be denied when billed for Commercial members. Examples cited in the policy include CPT 53899 (unlisted procedure, urinary system) and the electrical stimulation codes 97032 and 97014, as well as HCPCS E0740.

Coverage and payment for any service are governed by the member’s subscriber agreement, member certificate, and/or the employer agreement; those contract documents supersede this medical policy. This policy is provided for informational purposes and is not a guarantee of payment. Verify member-specific benefits and prior authorization requirements with the provider call center before delivering services.

Electrical or magnetic pelvic floor stimulation for fecal incontinence is considered not covered / not medically necessary because the evidence is insufficient to determine a net health benefit. Randomized trials of electrical stimulation for fecal incontinence are limited (only one sham-controlled trial did not show benefit), systematic reviews have not demonstrated superiority versus control interventions, and there are no randomized trials identified for magnetic stimulation. For Medicare Advantage members the policy explicitly states electrical or magnetic PFS for fecal incontinence is not covered due to insufficient evidence.

Coding

Medicare Advantage - Unlisted CPTCPTCovered

53899

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

Medicare Advantage - Related CPT 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

Medicare Advantage - HCPCSHCPCSCovered

E0740

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

Commercial Products - Unlisted CPTCPTNot Covered

53899

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

Commercial Products - Related CPT CodesCPTNot Covered

97032	Application of a modality to one Or more areas; electrical stimulation (manual), each 15 minutes
97014	Application of a modality to one Or more areas; electrical stimulation (unattended)

Commercial Products - HCPCSHCPCSNot Covered

E0740

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

Fecal incontinence - CPTCPT

53899

Unlisted procedure (use when no specific CPT exists for fecal incontinence services)

Provider Actions & Documentation

Denial Risk

Denial Risk for Commercial Products

Pelvic floor electrical or magnetic stimulation for urinary and fecal incontinence is a contract exclusion for Commercial Products and related CPT/HCPCS codes will be denied when billed for these services.

Affected codes (Commercial Products - not covered): CPT 53899 (Unlisted procedure, urinary system), CPT 97032, CPT 97014; HCPCS E0740
Providers should not bill members for excluded services unless informed written consent is obtained per payer rules.

Prior Authorization

Required Trial of Pelvic Muscle Exercises (PME)

For Medicare Advantage members, pelvic floor electrical stimulation is covered only after a documented failed trial of pelvic muscle exercises (PME). The trial must show no clinically significant improvement in urinary continence after completing at least 4 weeks of an ordered PME program intended to increase periurethral muscle strength.

Background

Pelvic floor stimulation (PFS) refers to non‑implantable therapies that apply electrical or extracorporeal magnetic energy to the pelvic floor or pudendal nerve to strengthen and exercise pelvic floor musculature. Electrical PFS is typically delivered via vaginal or anal probes connected to an external generator; magnetic PFS is delivered extracorporeally (for example, via a chair with embedded magnets). Parameters that vary across devices and studies include electrode or coil location, stimulus frequency (Hz), intensity/amplitude (mA), duty cycle, session duration, number of treatments per week, total treatment course, and whether therapy is provided in clinic or at home. The intended mechanism is neuromuscular electrical stimulation to improve periurethral and pelvic floor muscle function and thereby reduce stress and/or urge urinary incontinence.

Definitions

Pelvic floor stimulation (PFS) — non-implantable electrical or magnetic stimulation definition

DefinitionNon-implantable pelvic floor stimulation (PFS) — electrical stimulation delivered via vaginal or anal probes connected to an external generator, or extracorporeal magnetic stimulation delivered by a chair with an embedded magnet, intended to stimulate pelvic floor musculature and pudendal nerve to improve urethral closure and muscle reinnervation.

Delivery methodsElectrical PFS: internal vaginal or anal probes wired to an external device; Magnetic PFS: extracorporeal electromagnetic pulses administered with a specialized chair (patients remain clothed).

SettingsTreatments may occur in a physician's office, physical therapy facility, or begin in clinic with subsequent home-based therapy using a rented or purchased stimulator; magnetic PFS is typically clinic‑based.

Stimulation parameters vary by clinical diagnosisParameters that vary include electrode location, stimulus frequency (Hz), intensity/amplitude (mA), duty cycle/duration, sessions per week, session length, and total treatment period.