CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence

Defines coverage and medical necessity for pelvic floor electrical and magnetic stimulation (non-implantable) as treatment for urinary and fecal incontinence for Blue Cross & Blue Shield of Rhode Island members, distinguishing Medicare Advantage Plans vs Commercial products and including coding guidance.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence

Policy CodePolicy N/A

Change TypeClarified coverage and exclusions

Effective DateApr 1, 2001

Next Review Date

Key ActionFor Medicare Advantage members, document that the patient completed an ordered 4-week plan of pelvic muscle exercises with no clinically significant improvement before covering pelvic floor electrical stimulation.

SourceLink

POLICY UPDATE CHANGES

Policy clarifies Medicare Advantage Plans cover non-implantable pelvic floor electrical stimulation for stress and/or urge urinary incontinence in cognitively intact patients who failed a documented 4-week PME trial.

Commercial products do not cover pelvic floor electrical or magnetic stimulation for urinary or fecal incontinence (contract exclusion).

Pelvic floor electrical stimulation for fecal incontinence is not covered for Medicare Advantage Plans; magnetic PFS for fecal incontinence has no identified studies and is considered not medically necessary.

1Covered Indications (Medicare Advantage)

0Covered Indications (Commercial)

4 weeks

Required PME trial length

Coverage Summary

This policy addresses non-implantable pelvic floor electrical and extracorporeal magnetic stimulation as nonsurgical treatments for urinary and fecal incontinence, distinguishing Medicare Advantage Plans versus Commercial products. For Medicare Advantage Plans, non-implantable pelvic floor electrical stimulation is covered for treatment of stress and/or urge urinary incontinence in cognitively intact patients who have failed a documented 4-week pelvic muscle exercise (PME) trial. Pelvic floor electrical stimulation for fecal incontinence is not covered for Medicare Advantage Plans, and magnetic PFS for fecal incontinence is considered not medically necessary due to no identified studies. For Commercial products, pelvic floor electrical or magnetic stimulation for urinary or fecal incontinence is not covered (contract exclusion). Effective date: 2001-04-01. Policy last reviewed: 2023-08-16.

Key thresholds and quick facts

Required PME trial duration4 weeks

Covered Indications (Medicare Advantage)Urinary incontinence (non-implantable electrical) when criteria met

Covered Indications (Commercial)None — contract exclusions

Coverage stancemixed

Medical Necessity / Coverage Criteria

Medicare Advantage Plans - Urinary Incontinence (Covered)

Covered when ALL of the following are met:

ALL of the following

Non-implantable electrical stimulation indication: Pelvic floor electrical stimulation with a non-implantable stimulator is for the treatment of stress and/or urge urinary incontinence
Cognitive status: Patient is cognitively intact
PME trial failure: Patient has failed a documented trial of pelvic muscle exercise (PME) training4 weeks
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.

Coding Guidance

Covered CPT/Unlisted for Medicare Advantage Plans (Urinary Incontinence)CPTCovered

53899

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

Covered CPT Modalities (Medicare Advantage Plans)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 for Medicare Advantage PlansHCPCSCovered

E0740

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

Not Covered CPT (Commercial Products)CPTNot Covered

53899

Unlisted procedure, urinary system (to be used for magnetic stimulation for the treatment of incontinence) - not covered for Commercial Products

Denied/Not Covered CPT Modalities (Commercial Products)CPTNot Covered

97032	Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes - will be denied as non-covered when used for pelvic floor stimulation
97014	Application of a modality to one or more areas; electrical stimulation (unattended) - will be denied as non-covered when used for pelvic floor stimulation

Not Covered HCPCS (Commercial Products)HCPCSNot Covered

E0740

Incontinence treatment system, pelvic floor stimulator, monitor; sensor and/or trainer - not covered for Commercial Products

Coding for Fecal Incontinence (Both Medicare Advantage and Commercial)CPT

unlisted

There are no specific CPT codes for pelvic floor stimulation for fecal incontinence; an unlisted code should be used

Provider Actions & Billing Impacts

Prior Authorization

No prior authorization applicable per policy text (Not applicable under PRIOR AUTHORIZATION).

Documentation Required

Document failed trial of PME

For Medicare Advantage members, document that the patient completed an ordered 4-week plan of pelvic muscle exercises (PME) with no clinically significant improvement before covering pelvic floor electrical stimulation. A failed PME trial 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.

Definition: Failed trial of pelvic muscle exercise (PME) — 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.

Background, Evidence & Definitions

Pelvic floor stimulation (electrical or extracorporeal magnetic) is proposed to strengthen pelvic floor musculature to treat urinary and fecal incontinence. Electrical stimulation is generally delivered via vaginal or anal probes connected to an external generator; magnetic stimulation is delivered extracorporeally using a specialized chair in which the patient sits fully clothed. Methods vary in probe location, stimulus frequency and intensity, session duration, and setting (office, physical therapy, or home).

The overall evidence from randomized controlled trials and systematic reviews is mixed or insufficient. For urinary incontinence, electrical PFS has shown inconsistent benefits in systematic reviews and meta-analyses, and magnetic PFS trials are few, small, and heterogeneous with insufficient evidence to draw firm conclusions. For fecal incontinence, RCTs and systematic reviews have not demonstrated clear benefit of electrical stimulation, and there are no RCTs identified for magnetic PFS; evidence is insufficient to determine effects on health outcomes.

Evidence Source	Summary
Systematic reviews / RCTs	Electrical PFS: systematic reviews and RCTs show inconsistent or insufficient benefit for urinary incontinence; magnetic PFS: limited RCTs with short follow-up, methodological limitations, and heterogeneity; evidence insufficient for fecal incontinence
FDA 510(k)	Multiple non-implantable electrical and magnetic stimulators have FDA 510(k) clearance (examples: MyoTrac Infiniti 2006; ApexM 2015; NeoControl magnetic 2000; InTone MV 2014)
searchable':false

Failed trial of pelvic muscle exercise (PME): 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.

Non-implantable pelvic floor electrical stimulator: A device delivering neuromuscular electrical stimulation via vaginal or anal probes connected to an external generator to strengthen pelvic floor musculature.

Magnetic pelvic floor stimulation: Extracorporeal electromagnetic stimulation delivered via an embedded magnet in a specialized chair; patients sit fully clothed during treatment.

Revision History

2001-04-01effective

Policy effective date.

2023-08-16last_reviewLatest

Policy last reviewed.

2023-08-16material_changeLatest

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence

Policy CodePolicy N/A

Change TypeClarified coverage and exclusions

Effective DateApr 1, 2001

Next Review Date

SourceLink

On This Page

Medicare Advantage Plans - Urinary Incontinence (Covered)

Medicare Advantage Plans - Fecal Incontinence (Not Covered)

Not covered when ANY of the following apply:

ANY of the following

Electrical PFS for fecal incontinence - insufficent evidence: Pelvic floor electrical stimulation with a non-implantable stimulator for fecal incontinence is not covered; evidence is insufficient to determine the effects of the technology on health outcomes
Electrical or magnetic PFS for fecal incontinence - not medically necessary: Electrical or magnetic pelvic floor stimulation as a treatment of fecal incontinence is considered not medically necessary

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Medicare Advantage Plans - Fecal Incontinence (Not Covered)

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Commercial Products - Urinary and Fecal Incontinence (Not Covered / Contract Exclusion)

Commercial product coverage status:

ANY of the following

Electrical PFS for urinary incontinence - contract exclusion: Pelvic floor electrical stimulation for urinary incontinence is not covered and considered a contract exclusion
Magnetic PFS for urinary incontinence - contract exclusion: Pelvic floor magnetic stimulation for urinary incontinence is not covered and considered a contract exclusion
Electrical or magnetic PFS for fecal incontinence - contract exclusion: Pelvic floor electrical or magnetic stimulation for fecal incontinence is not covered and considered a contract exclusion

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Commercial Products - Urinary and Fecal Incontinence (Not Covered / Contract Exclusion)

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Billing Rule

Use unlisted CPT for magnetic stimulation (Medicare Advantage)

Use CPT 53899 (unlisted procedure, urinary system) for magnetic stimulation for the treatment of incontinence for Medicare Advantage Plans. For electrical stimulation services, CPT codes 97014 (electrical stimulation, unattended) and 97032 (electrical stimulation, manual, each 15 minutes) are covered when used for these services. HCPCS E0740 (incontinence treatment system, pelvic floor stimulator; monitor; sensor and/or trainer) is covered for Medicare Advantage Plans.

Affected codes: 53899, 97014, 97032, E0740
Guidance: use 53899 for magnetic stimulation; 97014 and 97032 acceptable for electrical stimulation when applicable.

Denial Risk

Commercial product denials

Claims for pelvic floor electrical or magnetic stimulation for urinary or fecal incontinence under Commercial products will be denied as non-covered or considered a contract exclusion. This includes CPT 97014, 97032, 53899 and HCPCS E0740 when used for these services.

Commercial product denials apply to CPT codes 97014, 97032, 53899 and HCPCS E0740 — these will be denied or are not covered as contract exclusions.

2023-08-16material_changeLatest

Policy clarifies commercial products do not cover pelvic floor electrical or magnetic stimulation for urinary or fecal incontinence (contract exclusion).

2023-08-16material_changeLatest

Policy clarifies pelvic floor electrical stimulation for fecal incontinence is not covered for Medicare Advantage Plans; magnetic pelvic floor stimulation for fecal incontinence has no identified studies and is considered not medically necessary.