CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence

Coverage and coding guidance for electrical and magnetic pelvic floor stimulation (PFS) as treatments for urinary and fecal incontinence for Blue Cross & Blue Shield of Rhode Island products, with separate stances for BlueCHiP for Medicare and 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 change

Effective DateApr 1, 2001

Next Review DateN/A

Key ActionDocument a failed 4‑week trial of pelvic muscle exercises (PME) before coverage for BlueCHiP for Medicare applies.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CoveredMedicare coverage

Not coveredCommercial coverage

Not requiredPrior auth

E0740Medicare HCPCS

97014/97032Commercial denied codes

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Coverage Criteria

BlueCHiP for Medicare - Medical Necessity

Covered when ALL of the following are met

Medicare coverage conditions: Non-implantable pelvic floor electrical stimulation is intended to treat stress and/or urge urinary incontinence.

Stimulation is generally delivered by vaginal or anal probes connected to an external generator; coverage applies to non-implantable electrical stimulators delivered by vaginal or anal probes or equivalent external devices.

Cognitive status: Patient is cognitively intact.

Per Medicare national coverage determination, cognitive intactness is required for coverage.

Failed conservative therapy: 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.PME trial = 4 weeks

Documentation of the failed 4-week PME trial must be in the medical record prior to coverage determination.

Commercial - Not Covered

Commercial product coverage stance

Commercial exclusion: Pelvic floor electrical stimulation for urinary and fecal incontinence is not covered and is a contract exclusion for Commercial products.

Specific modality and device codes used for pelvic floor stimulation (including CPT 97032, 97014, HCPCS E0740, and unlisted CPT 53899) will be denied for Commercial products.

Fecal Incontinence - Not Medically Necessary

Fecal incontinence: Electrical or magnetic pelvic floor stimulation for fecal incontinence is considered not medically necessary due to insufficient evidence; BlueCHiP for Medicare does not cover pelvic floor stimulation for fecal incontinence and Commercial products exclude it.

Only one sham-controlled trial of electrical stimulation for fecal incontinence showed no benefit; no studies identified for magnetic pelvic floor stimulation in fecal incontinence.

Pelvic floor electrical stimulation for urinary and fecal incontinence is a contract exclusion for Commercial products and is not covered.

Electrical or magnetic pelvic floor stimulation (PFS) is considered not medically necessary for urinary incontinence because randomized controlled trials have not consistently demonstrated improved net health outcomes versus placebo or other conservative treatments, and meta-analyses have produced mixed findings. Evidence is also insufficient for postprostatectomy incontinence and for magnetic PFS in men or women. For fecal incontinence, randomized trials (including only one sham-controlled trial) and systematic reviews did not show benefit; no studies were identified for magnetic PFS. Consequently, electrical or magnetic PFS for fecal incontinence is also considered not medically necessary.

Coding

BlueCHiP Medicare covered CPT (unlisted)CPTCovered

53899

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

Adjunct CPT modality codesCPT

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)

HCPCS floor stimulatorHCPCS

E0740

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

Commercial CPT (unlisted) and denialsCPTNot Covered

53899

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

PME trial duration — 4 weeks

PME trial duration4 weeks

ContextDefined as the period after which no clinically significant improvement in urinary continence is judged following an ordered PME plan

Applies toBlueCHiP for Medicare medical necessity requirement

Documentation requirementMust be documented as a failed trial of PME prior to coverage for non-implantable pelvic floor electrical stimulation

Provider Actions & Billing Notes

Prior Authorization

Prior authorization review is not required.

Step Therapy

PME Trial Requirement

Trial of pelvic muscle exercise (PME) training is required and must be documented as failed before coverage for BlueCHiP for Medicare. 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.

PME trial duration: 4 weeks
Documentation: must show completion of PME program and lack of clinical improvement

Denial Risk

Background

Pelvic floor stimulation (PFS) refers to electrical or extracorporeal pulsed magnetic stimulation applied to the pelvic floor musculature or pudendal nerve to promote urethral closure and neuromuscular reinnervation. Delivery methods vary and include vaginal or anal probes wired to an external generator, or external chair-based magnetic systems. Treatment parameters differ by probe location, stimulus frequency (Hz), stimulus intensity or amplitude (mA), duty cycle, session length, total course duration, and whether therapy is clinic-based or home-based with training. The therapeutic intent is to strengthen and exercise pelvic floor muscles to improve stress and/or urge urinary incontinence.

Definitions

Pelvic floor stimulation (PFS) — definition and delivery methods

DefinitionElectrical or extracorporeal pulsed magnetic stimulation applied to pelvic floor musculature to stimulate the pudendal nerve and activate pelvic floor muscles

Delivery methods - electricalVaginal or anal probes connected to an external generator; clinic-based or initial clinic training followed by home use with rented/purchased stimulators

Delivery methods - magneticExtracorporeal pulsed magnetic stimulation delivered via a chair-based device while the patient sits fully clothed on a specialized chair with an embedded magnet

Intended effectStrengthen and exercise pelvic floor musculature to improve urethral closure and promote reinnervation

Failed trial of pelvic muscle exercise (PME) — definition

Definition of failed PME trial