ModifiednorthwoodPolicy 470

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.

Policy Summary

Payernorthwood

PolicyNon-Implantable Pelvic Floor Electrical Stimulator

Policy CodePolicy Policy 470

Change TypeMaterial updates — added WellSense special coverage marking E0740 as experimental/investigationalclarified E0746 not covered for home use for Medicare members

Effective DateAug 20, 2025

Last ReviewNov 12, 2025

Next Review DateNov 12, 2025

Key ActionObtain prior authorization and document a 4-week trial of pelvic muscle exercises and required ICD-10 diagnosis when submitting for biofeedback or PFES services.

SourceLink

POLICY UPDATE CHANGES

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.

E0740, E0746HCPCS codes referenced

Medicare exceptionMedicare coverage possible

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ModifiednorthwoodPolicy 470

Non-Implantable Pelvic Floor Electrical Stimulator

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Sign up for northwood Policy 470 alerts

Get alerted when Policy 470 changes without checking for updates manually.

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Policy Summary

Payernorthwood

PolicyNon-Implantable Pelvic Floor Electrical Stimulator

Policy CodePolicy Policy 470

Change TypeMaterial updates — added WellSense special coverage marking E0740 as experimental/investigationalclarified E0746 not covered for home use for Medicare members

Effective DateAug 20, 2025

Last ReviewNov 12, 2025

Next Review DateNov 12, 2025

Key ActionObtain prior authorization and document a 4-week trial of pelvic muscle exercises and required ICD-10 diagnosis when submitting for biofeedback or PFES services.

SourceLink

POLICY UPDATE CHANGES

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.

E0740, E0746HCPCS codes referenced

Medicare exceptionMedicare coverage possible

Non‑Medicare stance

4Max biofeedback sessions

AnnualReview frequency

Coverage Criteria

Medicare Coverage Criteria (per CMS NCD 230.8)

Covered when ALL of the following are met:

Medicare criteria: 1) Ordered by the member's treating practitioner; 2) Member is cognitively intact with a diagnosis of stress and/or urge incontinence; 3) Member has failed a documented trial of pelvic muscle exercise training defined as completion of a four-week plan with no clinically significant improvement.4-week trial

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:

Plan stance: Non‑implantable pelvic floor stimulation (including PFES and pelvic floor magnetic stimulation/EMS) is considered experimental and investigational or not medically necessary for treatment of overactive bladder, urinary incontinence and/or fecal incontinence for 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

Applicable HCPCS Level II CodesHCPCS

E0746	Electromyography (EMG), biofeedback device
E0740	Non-implanted Pelvic Floor Electrical Stimulator, complete system.

Codes Considered Experimental/Not Medically Necessary for specified indicationsCPT|HCPCSNot Covered

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

Biofeedback deviceHCPCS

E0746

Electromyography (EMG), biofeedback device

Required primary ICD-10 diagnosis codes when billing pelvic floor stimulationICD-10

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)

1–10 of 15

1/2

Special Coverage / ExperimentalHCPCSExperimental

E0740

Non-Implantable Pelvic Floor Stimulator (referenced as experimental and investigational per WellSense criteria)

Plan-specific Not CoveredHCPCSNot Covered

E0746

Biofeedback device (not covered for home use for Medicare members per 10-22-24 entry)

inv-17: Pelvic muscle exercise trial — 4 weeks

Required duration4 weeks of documented pelvic muscle exercise (PME) training with no clinically significant improvement

PurposePrerequisite conservative therapy prior to biofeedback or PFES for urinary or fecal incontinence

Documentation locationMust be documented in the member's medical record

inv-18: Biofeedback sessions authorized — up to 4 sessions

Maximum authorized sessionsUp to 4 biofeedback training sessions

Provider Actions and Documentation

Prior Authorization

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

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.

Note

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.

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

inv-33: Pelvic floor electrical stimulator — device definition and use

DefinitionA device used in the treatment of urinary incontinence that delivers electrical current to pelvic floor muscles to induce contractions

Common useUsed for treatment of urinary incontinence and may be used for pelvic floor stimulation (PFES) or pelvic floor magnetic stimulation

Coding referenceNon-implanted PFES is reported with HCPCS E0740 (complete system) where applicable

inv-34: Biofeedback training — therapeutic training using EMG/biofeedback (E0746) authorized for up to 4 sessions when criteria met

DescriptionTherapeutic training using EMG/biofeedback to manage pelvic floor dysfunction symptoms

HCPCS codeE0746 — Electromyography (EMG), biofeedback device

Policy Summary

Payernorthwood

PolicyNon-Implantable Pelvic Floor Electrical Stimulator

Policy CodePolicy Policy 470

Change TypeMaterial updates — added WellSense special coverage marking E0740 as experimental/investigationalclarified E0746 not covered for home use for Medicare members

Effective DateAug 20, 2025

Last ReviewNov 12, 2025

Next Review DateNov 12, 2025

Key ActionObtain prior authorization and document a 4-week trial of pelvic muscle exercises and required ICD-10 diagnosis when submitting for biofeedback or PFES services.

SourceLink

On This Page

Therapeutic EMG/biofeedback (e.g., E0746) used to manage pelvic floor dysfunction symptoms

RequirementSessions to be used as part of documented plan when clinical criteria are met

inv-19: Chronic dyssynergic-type constipation treatment — failed 3 months of conventional treatment

Definition for this indicationChronic dyssynergic-type constipation in members age 18 or older

Prior therapy requirementFailed 3 months of conventional treatment including laxatives, dietary changes (e.g., high-fiber diet), and attempting defecation after meals

DocumentationFailure of conventional treatment must be documented in the medical record

Step Therapy

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.

Step Therapy

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.

Documentation Required

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).

Documentation Required

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.

Billing Rule

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.

Documentation Required

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.

Denial Risk

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

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.

Denial Risk

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.

Authorization limitAuthorized for up to 4 sessions when clinical criteria are met

inv-35: Non-implantable pelvic floor electrical stimulator (PFES) — definition and note that E0740 considered experimental/investigational for some products

DefinitionNon-implanted device used to deliver electrical stimulation to pelvic floor muscles (reported with HCPCS E0740)

Plan stanceConsidered experimental and investigational for non‑implantable PFES in specified commercial/plan products (WellSense criteria) and may be non‑covered

Notes on codingE0740 is the code used for non-implantable pelvic floor electrical stimulator, complete system; related CPT codes (e.g., 97014, 97032, G0283) have plan-specific restrictions