CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy | Transvaginal and Transurethral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence

Defines coverage stance for transvaginal radiofrequency bladder neck suspension and transurethral radiofrequency tissue remodeling (e.g., Renessa, SURx) for treatment of urinary stress incontinence for Commercial Products; notes Blue CHiP for Medicare has related policy. Applies to Commercial Products only.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy | Transvaginal and Transurethral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence

Policy CodePolicy N/A

Change TypeClarified (Commercial products applicability)

Effective DateFeb 7, 2009

Next Review Date

Key ActionRefer to the member's Benefit Booklet or Subscriber Agreement for benefits and eligibility; providers may not charge members for services determined not medically necessary unless the member was informed and agreed in writing in advance.

SourceLink

POLICY UPDATE CHANGES

Policy applies to Commercial Products only; related Blue CHiP for Medicare policy referenced.

Not medically necessaryCommercial coverage stance

1Explicit CPT code listed as not medically necessary

1Unlisted CPT code referenced for transvaginal procedure

Scope: Applies to Commercial Products only and addresses transvaginal radiofrequency bladder neck suspension (e.g., SURx) and transurethral radiofrequency tissue remodeling (e.g., Renessa). Coverage stance: these procedures are considered not medically necessary / cosmetic for Commercial Products. Effective date: 02/07/2009. Last review: 04/02/2020. Related: see Related BlueCHiP for Medicare National and Local Coverage Determinations reference for Medicare.

Key facts

Commercial coverage stanceNot medically necessary (Commercial Products)

Explicit CPT code listed as not medically necessary53860

Unlisted CPT code referenced for transvaginal procedure53899

Policy statusCURRENT

Policy subjectTransvaginal and Transurethral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence

Medical Necessity / Coverage Determinations

Commercial Products Coverage Determination

Policy statements for commercial products:

ALL of the following

Transvaginal radiofrequency bladder neck suspension is not medically necessary as the evidence is insufficient to determine the effects of the technology on health outcomes.
Transurethral radiofrequency tissue remodeling (including Renessa™ and similar devices) is not medically necessary as the literature and scientific evidence supporting these procedures is insufficient.

Coding-specific statements

Not medically necessary coding

CPT code 53860: Transurethral, radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence — considered not medically necessary for transurethral radiofrequency tissue remodeling.
Transvaginal radiofrequency bladder neck suspension: No specific CPT code; use CPT 53899 (unlisted procedure, urinary system) if billed.

Coding

Not medically necessary / Commercial ProductsCPTNot Covered

53860	Transurethral, radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence
53899	Unlisted procedure, urinary system (may be used for transvaginal radiofrequency bladder neck suspension)

Coding guidance: CPT 53860 (transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra) is considered not medically necessary for transurethral radiofrequency tissue remodeling. For transvaginal radiofrequency bladder neck suspension there is no specific CPT code; use 53899 (unlisted procedure, urinary system) if billed.

Provider Actions & Documentation

Documentation Required

Benefit verification and member agreement

Benefits and eligibility vary by group/contract; refer to the member's Benefit Booklet or Subscriber Agreement for services not medically necessary. If services are determined not medically necessary, providers may not charge the member unless the member was informed and agreed in writing in advance to continue at their own expense.

Verify member benefits and eligibility prior to providing services.
Do not bill the member for services determined not medically necessary unless the member was informed and provided written agreement in advance to continue at their own expense.

Billing Rule

Coding guidance for radiofrequency bladder/urethral procedures

There is no specific CPT code for transvaginal radiofrequency bladder neck suspension; CPT 53899 (unlisted procedure, urinary system) would be used. For transurethral radiofrequency micro-remodeling, CPT 53860 (Transurethral, radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence) is specifically listed as not medically necessary for Commercial Products.

Use CPT 53899 for transvaginal radiofrequency bladder neck suspension (no specific CPT exists).
Do not use CPT 53860 for transurethral radiofrequency tissue remodeling for Commercial Products (considered not medically necessary).

Background and Evidence Summary

Background: Radiofrequency (RF) tissue remodeling uses nonablative RF energy to shrink and stabilize the endopelvic fascia to improve support for the urethra and bladder neck in urinary stress incontinence. The SURx transvaginal system applies RF energy over exposed endopelvic fascia via a vaginal incision to produce blanching and tissue shrinkage. The Renessa transurethral procedure delivers RF energy via a 4-needle probe introduced through the urethra and bladder neck to denature collagen at tissue temperatures of about 65–75°C at multiple sites. The literature consists of multiple small studies, but overall the evidence is insufficient to support clinical effectiveness, and these services are considered not medically necessary for Commercial products.

Term	Definition
Evidence
Multiple small studies cited (2002–2011) but overall evidence deemed insufficient to determine health outcomes.
Urinary stress incontinence
Involuntary loss of urine from the urethra due to an increase in intra-abdominal pressure.
Transurethral radiofrequency micro-remodeling
Procedure delivering RF energy transurethrally (e.g., Renessa) to denature collagen at bladder neck/upper urethra.
Transvaginal radiofrequency bladder neck suspension
Surgical approach using RF applied over endopelvic fascia via vaginal incision (e.g., SURx) to shrink/stabilize fascia.

Revision History

2009-02-07effective

Policy effective date: 02/07/2009.

2020-04-02last_reviewLatest

Policy last updated/reviewed: 04/02/2020.

change