ProACT Adjustable Continence Therapy
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Medical policy governing coverage and medical necessity criteria for ProACT adjustable continence therapy for male post-prostate surgery stress urinary incontinence for CareSource Georgia members.
Review: removed age criteria.
Coverage and Medical Necessity Criteria
Initial Therapy
CareSource considers ProACT adjustable continence therapy medically necessary when ALL the following clinical criteria are met:
Document requirement from policy D.I.A
Document requirement from policy D.I.B
Conservative therapies must have been tried and failed per policy D.I.C
Document requirement from policy D.I.D
Document requirement from policy D.I.E
CareSource considers ProACT contraindicated in members with any of the following conditions: urge urinary incontinence; detrusor instability or over‑activity; post‑void residual volume of at least 100 mL or residual volume equal to ≥ 25% of total bladder capacity after voiding; active systemic or urinary tract infection; history of bladder stones; hemophilia or other bleeding disorders; reduced bladder compliance; suspected bladder cancer; or radiotherapy within the past 6 months. These exclusions must be reviewed and documented during prior authorization and clinical evaluation.
Providers should also note the policy lists duplicate phrasings of the residual volume threshold (e.g., “residual volume of at least 100ml” and “residual urine volume exceeding 100 cubic centimeters”), which reflect the same contraindication threshold of 100 mL.
Urinary incontinence that is primarily due to detrusor instability or an overactive bladder is specifically identified as a contraindication and therefore is not an appropriate indication for ProACT. Prior authorization documentation must demonstrate that the member’s incontinence is stress urinary incontinence from intrinsic sphincter deficiency rather than urge‑predominant symptoms before ProACT will be considered.
Clinical Thresholds and Definitions for Coding
Prior Authorization, Documentation, and Denial Conditions
Obtain prior authorization with full medical necessity documentation
Prior authorization is required and must be obtained before coverage determination. Submitted authorization documentation must demonstrate that all medical necessity criteria are met.
Document prior conservative therapy and failure
Documented failure of conservative management is required before ProACT will be considered. Conservative therapies include lifestyle modification, pads, compression, catheters, and pelvic floor exercises — these must have been tried and failed.
- Conservative therapies listed: lifestyle modification, pads, compression, catheters, pelvic floor exercises.
- Failure of these conservative measures must be documented prior to consideration of ProACT.
Include required clinical documentation with authorization
Provide clinical records showing radical prostatectomy or TURP performed at least 12 months prior (with no radiation therapy), documented primary stress urinary incontinence from intrinsic sphincter deficiency of ≥12 months duration, frequency of incontinence (≥3/day), and two positive 24-hour pad weight tests showing ≥8 g increase.
- Surgery timing: radical prostatectomy or transurethral resection of the prostate ≥12 months prior and no radiation therapy.
- Diagnosis: primary SUI due to intrinsic sphincter deficiency lasting ≥12 months.
- Symptom frequency: at least 3 incontinence episodes per day.
- Objective testing: two 24‑hour pad weight tests each showing ≥8‑gram pad weight increase.
Denial risk if medical necessity criteria or contraindication status not met
Service may be denied if the member does not meet all listed medical necessity criteria or has any contraindication. Examples include less than 12 months since prostate surgery, lack of documented primary SUI of ≥12 months, fewer than 3 episodes per day, missing or negative pad weight tests, or contraindications such as urge incontinence, detrusor overactivity, residual volume ≥100 ml, active infection, recent radiotherapy, or bleeding disorders.
- Insufficient time since surgery (<12 months) or radiation within prior 6 months.
- Insufficient documentation of primary SUI lasting ≥12 months or failure of conservative therapy.
- Fewer than 3 incontinence episodes per day or absence of two positive 24‑hour pad weight tests (≥8 g).
- Any listed contraindication (e.g., urge incontinence, detrusor instability/overactivity, post-void residual ≥100 ml or ≥25% bladder capacity, active systemic or urinary tract infection, history of bladder stones, hemophilia/bleeding disorders, suspected bladder cancer).
Clinical Background and Context
Urinary incontinence is a recognized complication following prostate surgery and many patients improve without surgery. Following radical prostatectomy or TURP, symptoms commonly improve over time with conservative management (for example: behavioral measures, pads/compression, catheter management, and pelvic floor rehabilitation); only a small proportion of men ultimately proceed to an additional incontinence procedure. CareSource’s criteria require demonstration that conservative therapies have failed and that incontinence persists before considering ProACT, and they specify thresholds (including duration since surgery and objective pad‑weight testing) to distinguish persistent post‑prostate surgery stress urinary incontinence from transient postoperative recovery.
Definitions of Urinary Incontinence Types
Policy Review and Revision History
Policy effective date for ProACT Adjustable Continence Therapy; implements the updated clinical coverage criteria.
Annual review completed and references updated; review notes indicate removal of age criteria as a material change.
Annual review conducted (committee approval) with editorial updates and updated references.
Policy originally issued (New Policy).
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