Non-Implantable Pelvic Floor Electrical Stimulator
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Policy governs coverage and medical necessity determinations for non-implantable pelvic floor electrical and magnetic stimulation devices for treatment of urinary incontinence, overactive bladder, and fecal incontinence for Northwood plan members.
Added current WellSense criteria (experimental and investigational) for Non-Implantable Pelvic Floor Stimulator (E0740) to Special Coverage Information Per Plan box.
Added WellSense criteria for Biofeedback device and E0746 not covered for home use for Medicare members.
Added NCD to references.
Coverage Criteria
Medicare Coverage Criteria (per CMS NCD 230.8)
Covered when ALL of the following are met:
Home use of E0746 biofeedback therapy is not covered for Medicare members.
Non‑Medicare / All Plan Members Stance
Plan position for non‑Medicare and general Plan members:
All requests will be reviewed by a Plan Medical Director.
None.
Biofeedback is considered experimental and investigational or not medically necessary when Plan criteria are NOT met, when used for indications outside those specified by the Plan, or when used in the home setting; this reflects limited evidence supporting clinical utility and validity of home use biofeedback.
CMS guidance does not cover home use of biofeedback therapy. Per the Plan's variations and recent policy updates, HCPCS E0746 is not covered for home use for Medicare members and home use is excluded per CMS rules and Plan updates.
Per the policy change history and prior updates, E0746 is not covered for home use for Medicare members.
The Plan considers use of non‑implantable pelvic floor stimulation (including pelvic floor electrical stimulation, PFES, and pelvic floor magnetic stimulation/EMS) for the treatment of overactive bladder, urinary incontinence, and/or fecal incontinence to be experimental, investigational, or not medically necessary for Plan members; all requests will be reviewed by a Plan Medical Director and denials may result when criteria are not met.
HCPCS E0740 (Non‑implanted pelvic floor electrical stimulator) is identified by the Plan as experimental and investigational / non‑covered for non-implantable PFES in certain commercial products and per WellSense criteria; see Plan-specific guidance for applicable product rules.
The Plan's special coverage information was updated to add WellSense criteria that mark the Non‑Implantable Pelvic Floor Stimulator (E0740) as experimental and investigational for specified products; providers should follow product-specific prior authorization and coverage rules.
Coding and Billing Codes
| 97014 | Application of a modality to 1 or more areas; electrical stimulation (unattended) |
| 97032 | Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes |
| E0740 | Non-implanted pelvic floor electrical stimulator, complete system |
| G0283 | Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care |
| E0746 | Electromyography (EMG), biofeedback device |
| N32.81 | Overactive bladder |
| N32.9 | Bladder disorder, unspecified |
| N39.3 | Stress incontinence |
| N39.41 | Other specified urinary incontinence |
| N39.43 | Other specified urinary incontinence |
| N39.45 | Other specified urinary incontinence |
| N39.46 | Other specified urinary incontinence |
| N39.490 | Other specified urinary incontinence |
| N39.498 | Other specified urinary incontinence |
| R15.0 | Other specified urinary incontinence / fecal incontinence (range R15.0-R15.9) |
| E0740 | Non-Implantable Pelvic Floor Stimulator (referenced as experimental and investigational per WellSense criteria) |
| E0746 | Biofeedback device (not covered for home use for Medicare members per 10-22-24 entry) |
Provider Actions and Documentation
Follow Plan and CMS guidance for prior auth date
Requests for services will be reviewed and prior authorization requirements follow Plan and CMS guidance; verify CMS guidelines in effect on the date of the prior authorization request.
Prior authorization required for services meeting clinical criteria
Plan prior authorization is required for services specified in the Clinical Criteria and Limitations/Exclusions sections; providers are responsible for obtaining prior authorization even if an applicable code is not listed in the policy.
E0740 marked experimental/investigational in WellSense criteria
WellSense criteria were added marking HCPCS E0740 (Non‑Implantable Pelvic Floor Stimulator) as experimental and investigational per plan-specific special coverage information; prior authorization may be required per plan rules.
4‑week pelvic muscle exercise trial required (Medicare prerequisite)
Document a trial of pelvic muscle exercises (PME) of four weeks; this documented 4‑week PME trial is a required prerequisite for Medicare coverage.
- A failed trial is completion of a four‑week PME plan with no clinically significant improvement.
Prerequisite: 4‑week pelvic muscle exercise trial before biofeedback/PFES
Document a trial of 4 weeks of pelvic muscle exercise training with no significant improvement prior to providing biofeedback or PFES; this must be recorded in the member's medical record.
- Biofeedback training is authorized for up to 4 sessions when criteria are met.
Document required clinical and billing elements for auth/claims
Providers must ensure all required documentation elements are included in the medical record when requesting coverage or submitting claims: primary ICD-10 diagnosis from the allowed list, documentation of a 4‑week PME trial (when applicable), cognitive status, indication-specific findings, and number of planned sessions.
- Primary ICD-10 diagnosis code must be one of the codes listed in the policy when billing stimulation or biofeedback codes.
- Document cognitive status and indication-specific findings (e.g., rectal sensation/ability to contract sphincter for fecal incontinence).
- Record the documented 4‑week PME trial and the planned number of biofeedback sessions (up to 4).
Medicare ordering and clinical documentation requirements
For Medicare members, the device must be ordered by the treating practitioner and documentation must show the member is cognitively intact, has an appropriate diagnosis (stress and/or urge incontinence), and has failed a documented four‑week trial of pelvic muscle exercise training.
- Home use of E0746 biofeedback therapy is not covered for Medicare members.
Document and bill an allowed primary ICD-10 diagnosis
When billing stimulation or biofeedback codes, providers must document one of the primary ICD-10 diagnosis codes listed in the policy as the primary diagnosis on the claim and in the medical record.
- See the policy’s ICD-10 list (e.g., N32.81, N39.3, R15.0‑R15.9, R32) for allowed primary diagnoses.
Include NCD documentation with claims/PA when applicable
Policy references were updated to add the National Coverage Determination (NCD); include relevant NCD documentation when submitting claims or prior authorization requests.
- Verify and attach any applicable NCD documentation when applicable for Medicare members.
E0740 non‑covered for non‑Medicare members — expect denials
For Non‑Medicare members (e.g., commercial), HCPCS E0740 (Non‑implanted Pelvic Floor Stimulator) is considered experimental and investigational and is non‑covered; submitting claims for E0740 for non‑Medicare members may result in denial.
- All requests for this service will be reviewed by a Plan Medical Director.
Denial risk: codes flagged as experimental/not medically necessary
Claims billed with codes identified as experimental, investigational, or not medically necessary (for example E0740 for non‑implantable PFES in some products, and certain modality codes like 97014/97032/G0283 when used for incontinence indications) may be denied per Plan rules.
- Confirm clinical criteria and prior authorization before billing these codes for incontinence/fecal incontinence indications.
E0746 home use for Medicare members is not covered — denial risk
E0746 (EMG biofeedback device) is not covered for home use for Medicare members; claims for home use of E0746 for Medicare members may be denied.
- Outpatient biofeedback may be covered when clinical criteria are met and prior authorization is obtained, but home use is explicitly not covered for Medicare.
Background
Pelvic floor electrical stimulators deliver electrical current to the pelvic floor muscles to induce contractions and are used in the treatment of urinary incontinence. For Medicare members, CMS NCD guidance (NCD 230.8 referenced in the policy) provides medically necessary indications for non‑implantable pelvic floor electrical stimulators; Plan adoption of CMS guidance affects coverage determinations.
Definitions
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