RetiredCareFirstPolicy N/A

Archived Electrical Stimulation of the Pelvic Floor for Stress Urinary Incontinence

This archived policy addresses the use of electrical stimulation of the pelvic floor to treat stress urinary incontinence in adults and indicates the payer's coverage stance; it has been combined with a broader Treatments for Urinary Incontinence policy (#7.01.41).

Policy Summary

PayerCareFirst

PolicyArchived Electrical Stimulation of the Pelvic Floor for Stress Urinary Incontinence

Policy CodePolicy N/A

Change TypeArchived/Combined

Effective DateN/A

Next Review DateN/A

Key ActionRefer to the consolidated Treatments for Urinary Incontinence policy (#7.01.41) for current coverage and prior authorization requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

05/06/2004policy archived date

7.01.41combined policy

fails TEC #2-5experimental reason

archivedstatus

Coverage Determination

Not covered — Experimental/Investigational

Covered when ALL of the following are met

ALL of the following

Electrical stimulation of the pelvic floor for stress urinary incontinence is considered experimental/investigational.
The therapy does not meet the Technology Evaluation Center (TEC) criteria #2-5, and therefore is not covered under this policy.
This policy has been archived as of 05/06/2004 and has been combined with the Treatments for Urinary Incontinence policy (#7.01.41); refer to that consolidated policy for current coverage rules.

Claims for this therapy are at risk for denial because the therapy is designated experimental/investigational.

Policy Summary

PayerCareFirst

PolicyArchived Electrical Stimulation of the Pelvic Floor for Stress Urinary Incontinence

Policy CodePolicy N/A

Change TypeArchived/Combined

Effective DateN/A

Next Review DateN/A

Key ActionRefer to the consolidated Treatments for Urinary Incontinence policy (#7.01.41) for current coverage and prior authorization requirements.

SourceLink

On This Page

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Provider Actions and Billing Guidance

Note

Refer to consolidated policy #7.01.41

This policy has been archived and consolidated. Refer to CareFirst Medical Policy #7.01.41 (Treatments for Urinary Incontinence) for current coverage rules, clinical criteria, and documentation expectations.

Archived as of 2004-05-06 — do not use this policy for authorization or billing decisions.
All claims for pelvic floor electrical stimulation should be reviewed against the consolidated policy #7.01.41.

Note

Provider note — use consolidated policy

Provider action: This archived policy is no longer the authority. Use the consolidated Treatment for Urinary Incontinence policy for preauthorization, coverage determinations, and billing guidance. Contact medical policy prior to submitting claims when in doubt.

Do not submit prior authorization requests citing this archived policy.
If a request or claim is received for pelvic floor electrical stimulation, route review to the consolidated policy and document rationale per that policy.

Documentation Required

Documentation guidance — follow consolidated policy and include required clinical details

Documentation must follow the consolidated policy #7.01.41. Include clinical history, prior conservative therapy attempts (e.g., pelvic floor exercises, medication, biofeedback), objective findings, and indication that pelvic floor electrical stimulation is being considered consistent with criteria in the consolidated policy. Insufficient documentation may result in claim denial.

Document prior conservative treatments and duration.
Provide objective assessment of type of incontinence (stress vs. urge) and contributing factors.
Attach relevant progress notes, test results, and prior authorization approvals if applicable.

Denial Risk

Denial risk — experimental/investigational exclusion

Electrical stimulation of the pelvic floor for stress urinary incontinence is considered experimental/investigational per the archived policy. Claims not meeting criteria in the consolidated policy are at risk for denial.

Claims for pelvic floor electrical stimulation lacking documentation that meets consolidated policy criteria may be denied as experimental/investigational.
When denial is issued, include reference to the consolidated policy coverage criteria and the archived status of this policy.

Background

Urinary incontinence includes multiple types. Stress urinary incontinence is characterized by involuntary urine loss that occurs with increases in intra‑abdominal pressure such as coughing, sneezing, or physical exertion. Proposed non‑surgical management options have included pelvic floor muscle training (Kegel exercises), medication, biofeedback, and pelvic floor electrical stimulation, the latter aiming to increase sphincter tone by applying electrical muscle stimulation to the pelvic floor. This archived policy specifically addresses the electrical stimulation approach for stress incontinence.

Definitions

Definition — Stress urinary incontinence

TermStress urinary incontinence

DefinitionInvoluntary urine loss that occurs during activities that increase intra-abdominal pressure such as coughing, sneezing, straining, or other movements.

Typical causesOften the result of multiparity, aging, or following intra-abdominal surgery.

Common non-surgical treatmentsPelvic floor (Kegel) exercises and medication; pelvic floor stimulation has been proposed as an alternative.

Definition — Pelvic floor electrical stimulation

TermPelvic floor electrical stimulation

DefinitionUse of electrical muscle stimulation (EMS) applied to pelvic floor muscles intended to increase sphincter tone as a non-surgical treatment for urinary incontinence.

PurposeProposed to increase sphincter competence and relieve stress urinary incontinence symptoms.

ContextDescribed as one of several non-surgical treatment alternatives alongside Kegel exercises and medication.

OpenPayer

Archived Electrical Stimulation of the Pelvic Floor for Stress Urinary Incontinence

Coverage Determination

Coding

Provider Actions and Billing Guidance

Background

Definitions