CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Stress Incontinence

Commercial products only. Policy addresses the medical necessity and coverage stance for transvaginal radiofrequency bladder neck suspension and transurethral radiofrequency tissue remodeling for female stress urinary incontinence. Not applicable to Blue CHiP for Medicare (see related Medicare policies).

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyStress Incontinence

Policy CodePolicy N/A

Change Typeclarified

Effective DateFeb 7, 2009

Next Review Date

Key ActionDo not submit prior authorization for these procedures under Commercial Products since policy states prior authorization is not applicable and the procedures are considered not medically necessary; verify member-specific coverage via benefit booklet or subscriber agreement.

SourceLink

POLICY UPDATE CHANGES

Policy limited to Commercial Products and refers Blue CHiP for Medicare to related Medicare policy section.

1Primary non-covered procedure type

2CPT codes referenced

0Prior authorization required

Coverage Summary

Scope: Commercial Products only. This policy addresses the medical necessity and coverage stance for transvaginal radiofrequency bladder neck suspension and transurethral radiofrequency tissue remodeling for female stress urinary incontinence. For Blue CHiP for Medicare, see the related Medicare policy section (policy limited to Commercial Products).

Overview: Subject — Transvaginal and transurethral radiofrequency (RF) treatment for urinary stress incontinence. Payer — Commercial Products (Blue Cross/Blue Shield plan). Effective date — 02/07/2009. Policy last reviewed/updated — 08/21/2018.

Medical-Necessity Determination

Medical Necessity Determination

Commercial Products:

Medical Necessity Determination: Transvaginal radiofrequency bladder neck suspension and transurethral radiofrequency tissue remodeling are considered not medically necessary because evidence is insufficient to determine effects on health outcomes.

Not Medically Necessary / Not Covered

Coverage stance: For Commercial Products, transvaginal radiofrequency bladder neck suspension and transurethral radiofrequency tissue remodeling (Renessa) are considered not medically necessary because the evidence is insufficient to determine the effects of these technologies on health outcomes.

Coding

Not medically necessary codeCPTNot Covered

53860

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

Unlisted procedure for transvaginal radiofrequency bladder neck suspensionCPTNot Covered

53899

Unlisted procedure, urinary system (would be used for transvaginal radiofrequency bladder neck suspension as there is no specific CPT code)

Provider Actions

Documentation Required

Commercial coverage limitation

Do not submit prior authorization for these procedures under Commercial Products since policy states prior authorization is not applicable and the procedures are considered not medically necessary; benefits may vary by contract so verify member-specific coverage via benefit booklet or subscriber agreement.

Affected CPT codes: 53860, 53899
Verify member-specific coverage via the benefit booklet or subscriber agreement; contact the provider call center for member-specific benefits.

Billing Rule

Use of unlisted CPT for transvaginal procedure

If reporting transvaginal radiofrequency bladder neck suspension, CPT code 53899 (unlisted procedure, urinary system) would be used; however the policy deems the procedure not medically necessary for Commercial Products.

Affected CPT code: 53899
Procedure is considered not medically necessary for Commercial Products.

Background & Evidence

Background: Radiofrequency (RF) tissue remodeling has been investigated as a minimally invasive technique to shrink and stabilize the endopelvic fascia to treat female stress urinary incontinence. Two device/procedural approaches described are the SURx Transvaginal System (transvaginal RF bladder neck suspension, involving a vaginal incision and application of RF energy to the endopelvic fascia) and the Renessa transurethral RF collagen denaturation procedure (a 4-needle RF probe passed through the urethra with focal collagen denaturation at multiple sites). Conservative therapies (pelvic floor muscle exercises, biofeedback, electrical stimulation, periurethral bulking agents) and traditional surgical bladder suspension procedures are alternative treatments when conservative therapy fails.

Evidence summary: Insufficient evidence to determine the effects of transvaginal or transurethral RF procedures on health outcomes for stress urinary incontinence.

Definitions

Urinary stress incontinenceThe involuntary loss of urine from the urethra due to an increase in intra-abdominal pressure.

Medicare Determinations

Medicare determinations: Referenced as BlueCHiP for Medicare National and Local Coverage Determinations. Note: this policy is limited to Commercial Products; BlueCHiP for Medicare is addressed separately in related Medicare policy.

Revision History

2009-02-07effective

Policy effective date

2018-08-21last_reviewLatest

Policy last reviewed

change