Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence
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Policy governing coverage of non-implantable pelvic floor electrical and magnetic stimulation as treatments for urinary and fecal incontinence for Blue Cross & Blue Shield of Rhode Island members, with distinctions between Medicare Advantage and Commercial products.
No material clinical or coverage changes in this revision.
Coverage Criteria
Medicare Advantage: Covered indication and prerequisites
Covered when ALL of the following are met:
ALL of the following
- Member is enrolled in a Medicare Advantage Plan (BCBSRI follows CMS determinations).
- Indication is stress and/or urge urinary incontinence (not fecal incontinence).
- Treatment is pelvic floor electrical stimulation with a non-implantable stimulator (electrical stimulation only; magnetic stimulation is not covered).
- Patient is cognitively intact.
- There is documentation of a failed trial of pelvic muscle exercise (PME) training, 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.
This medical policy is provided for informational purposes and is not a guarantee of payment. Benefits and eligibility are determined by the member's subscriber agreement or employer agreement, which supersede this policy. For member-specific benefits, contact the provider call center. BCBSRI reserves the right to review and revise this policy at any time.
Evidence summary: Systematic reviews and randomized controlled trials of electrical pelvic floor stimulation for urinary incontinence have not consistently demonstrated improvement in net health outcomes compared with placebo or other conservative treatments; evidence is insufficient to determine effects on health outcomes. For magnetic stimulation in urinary incontinence, trials and reviews are limited by small numbers, short follow-up, methodological limitations, and heterogeneity, and the evidence is insufficient. For fecal incontinence, RCTs and systematic reviews do not show that electrical stimulation is superior to control interventions, and no RCT evidence exists for magnetic stimulation; evidence is insufficient to determine effects on health outcomes.
Coding and Billing
| 53899 | Unlisted procedure, urinary system (to be used for pulsed magnetic stimulation for the treatment of incontinence) |
| E0740 | Nonimplanted pelvic floor electrical stimulator, complete system |
Provider Actions and Billing Guidance
Prior Authorization
Not applicable
Payment / authorization advisory
This policy is informational. Prior authorization or member benefit verification may be required based on the member's specific benefits or plan; verify with the provider call center prior to rendering services.
- Prior authorization: verify per member benefits
- Policy informational — not a guarantee of payment
Commercial exclusion
For Commercial products, pelvic floor electrical or magnetic stimulation with a non-implantable stimulator for urinary and fecal incontinence is not covered and is a contract exclusion.
- Commercial exclusion: non-implantable electrical or magnetic PFS for urinary and fecal incontinence — not covered
Medicare noncoverage for specific indications
Medicare Advantage plans: magnetic stimulation for urinary incontinence and electrical or magnetic stimulation for fecal incontinence are not covered due to insufficient evidence. Electrical pelvic floor stimulation (non-implantable) is covered for stress and/or urge urinary incontinence only when Medicare criteria are met (see documentation requirements and PME trial).
- Magnetic PFS for urinary incontinence — not covered (Medicare Advantage)
- Electrical or magnetic PFS for fecal incontinence — not covered (Medicare Advantage)
- Electrical non-implantable PFS for stress/urge urinary incontinence — covered when Medicare criteria met
Member financial liability / Denial risk
Services that are determined to be not medically necessary or are non-covered benefits may expose the member to financial liability. Providers may not charge the member unless the member has been informed and provided written agreement to accept financial responsibility in advance.
- Member financial liability if service is non-covered or not medically necessary
- Obtain written member agreement before charging for non-covered services
Benefits verification
Verify member-specific benefits and eligibility with the provider call center prior to providing services. Coverage is governed by the member's subscriber agreement/certificate and employer agreement; those documents supersede this policy.
- Call provider call center for member-specific benefits and eligibility verification
- Subscriber agreement or member certificate governs coverage
Medicare Advantage documentation requirement
For Medicare Advantage coverage of non-implantable pelvic floor electrical stimulation, document a failed trial of pelvic muscle exercise (no clinically significant improvement after 4 weeks of an ordered PME program) and clinical rationale consistent with Medicare National Coverage Determination.
- Document failed trial of PME: no clinically significant improvement after 4 weeks of ordered pelvic muscle exercises
- Support coverage with clinical documentation per Medicare NCD
Background
Pelvic floor stimulation (PFS) is a nonsurgical therapy that uses electrical stimulation or extracorporeal pulsed magnetic stimulation to activate pelvic floor musculature and neuromuscular pathways. Electrical PFS can be delivered via vaginal or rectal probes or externally and may be administered in clinic or at home; magnetic PFS is typically delivered via an external chair that generates magnetic pulses and does not require internal electrodes. The proposed mechanisms include improving urethral closure and reinnervation of partially denervated muscles.
Definitions
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