ModifiedPremera BluecrossPolicy 1.01.17

Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence

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Defines coverage stance for electrical or magnetic pelvic floor stimulation used to treat urinary or fecal incontinence for members covered by Premera Blue Cross.

Policy Summary

PayerPremera Bluecross

PolicyPelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence

Policy CodePolicy 1.01.17

Change TypeReinstated and revised

Effective DateSep 4, 2026

Last ReviewMay 12, 2026

Next Review Date

Key ActionSubmit prior authorization when proposing non-implantable pelvic floor stimulators billed with CPT 53899 or HCPCS E0740 and document prior conservative treatments.

SourceLink

POLICY UPDATE CHANGES

Policy reinstated from Archive status and updated with literature review through July 7, 2025; effective for dates of service on or after September 4, 2026.

Electrical or magnetic stimulation of the pelvic floor muscles as a treatment for urinary or fecal incontinence is considered investigational.

Policy updated with multiple recent references and guideline citations through 2025/2026 (including AUA/SUFU, ASCRS, NICE, Cochrane reviews, and recent RCTs/systematic reviews).

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ModifiedPremera BluecrossPolicy 1.01.17

Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence

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Defines coverage stance for electrical or magnetic pelvic floor stimulation used to treat urinary or fecal incontinence for members covered by Premera Blue Cross.

Policy Summary

PayerPremera Bluecross

PolicyPelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence

Policy CodePolicy 1.01.17

Change TypeReinstated and revised

Effective DateSep 4, 2026

Last ReviewMay 12, 2026

Next Review Date

Key ActionSubmit prior authorization when proposing non-implantable pelvic floor stimulators billed with CPT 53899 or HCPCS E0740 and document prior conservative treatments.

SourceLink

POLICY UPDATE CHANGES

Policy reinstated from Archive status and updated with literature review through July 7, 2025; effective for dates of service on or after September 4, 2026.

Electrical or magnetic stimulation of the pelvic floor muscles as a treatment for urinary or fecal incontinence is considered investigational.

Policy updated with multiple recent references and guideline citations through 2025/2026 (including AUA/SUFU, ASCRS, NICE, Cochrane reviews, and recent RCTs/systematic reviews).

InvestigationalCoverage stance

Electrical & magneticModalities

NCD existsMedicare NCD

Archived→ReinstatedLifecycle

Jul 7, 2025Evidence cutoff

Coverage Criteria — Pelvic Floor Stimulation

Urinary incontinence — Investigational

Coverage stance

Investigational for urinary incontinence: Electrical or magnetic stimulation of the pelvic floor muscles as a treatment for urinary incontinence is considered investigational.

Examples include Regenesis EMS Chair, Emsella, NeoControl and vaginal/rectal probes.

Fecal incontinence — Investigational

Coverage stance

Investigational for fecal incontinence: Electrical or magnetic stimulation of the pelvic floor muscles as a treatment for fecal incontinence is considered investigational.

Systematic reviews and RCTs have not demonstrated consistent benefit; limited sham-controlled trials.

Investigational / Not medically necessary

Policy stance as stated in this segment

Investigational therapies: Electrical or magnetic stimulation of the pelvic floor muscles as a treatment for urinary or fecal incontinence is considered investigational.

Policy reinstated from Archive status and updated with literature review through July 7, 2025; effective for dates of service on or after September 4, 2026.

The policy identifies specific examples of devices used to deliver pelvic floor stimulation but clarifies the list is not exhaustive. Examples cited include the Regenesis EMS Chair, Emsella (formerly HPM-6000UF), NeoControl Pelvic Floor Therapy System, and various vaginal and rectal probes. These devices deliver electrical or magnetic pulses to the pelvic floor musculature and are referenced solely as examples of technologies evaluated under this policy.

This medical policy does not apply to Medicare Advantage members; refer to member benefit booklets or customer service for coverage determinations specific to individual plans.

Based on available evidence from systematic reviews and randomized trials, electrical or magnetic stimulation of the pelvic floor muscles for urinary or fecal incontinence is considered investigational. Systematic reviews and RCTs have not consistently demonstrated clinically meaningful improvements in symptoms, disease status, or quality of life compared with sham or other conservative treatments, and evidence for magnetic stimulation in fecal incontinence is lacking.

On reinstatement from archive, the policy restates the investigational classification: electrical or magnetic stimulation of the pelvic floor muscles as a treatment for urinary or fecal incontinence is considered investigational. The policy was updated with a literature review through July 7, 2025, and is effective for dates of service on or after September 4, 2026.

Coding

CPTCPT

53899

Unlisted procedure, urinary system

HCPCSHCPCS

E0740

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

Coding notemixed

No codes listed

Provider Actions and Billing Guidance

Prior Authorization

Prior Authorization Required

Prior authorization is required for requests involving non-implantable pelvic floor stimulators. Providers should submit prior authorization when proposing use of non-implantable pelvic floor stimulators (for example, devices billed with HCPCS E0740 or CPT unlisted code 53899) so medical necessity can be reviewed given the policy position that pelvic floor stimulation for urinary or fecal incontinence is considered investigational.

Affected codes: CPT 53899 (Unlisted procedure, urinary system); HCPCS E0740 (Incontinence treatment system; pelvic floor stimulator)
Submit prior authorization for dates of service on or after 2026-09-04

Billing Rule

Billing Guidance

Billing guidance: when pelvic floor stimulation services are billed, use the CPT unlisted code 53899 or HCPCS code E0740 as appropriate. Document the medical rationale and any prior conservative treatment attempts in the prior authorization and claim documentation.

Background

Pelvic floor stimulation (PFS) refers to delivery of electrical or magnetic pulses to activate pelvic floor muscles and associated pudendal nerve pathways to improve urethral and anal sphincter function. Delivery methods vary and include intracavitary probes (vaginal or rectal), chair-based extracorporeal magnetic stimulation, and other external applicators; stimulus parameters, treatment setting, and schedules also differ across devices and studies.

Definitions

Pelvic floor stimulation (PFS)

DefinitionPelvic floor stimulation (PFS) involves electrical stimulation of pelvic floor muscles using either an internal probe wired to a device or extracorporeal electromagnetic (magnetic) pulses delivered via a specialized chair; stimulation of the pudendal nerve may improve urethral closure and enhance reinnervation of denervated pelvic musculature.

Electrical modalitiesDelivered via vaginal or rectal probes or external electrodes with variable parameters (frequency, intensity/amplitude, pulse duration, pulse-to-rest ratio); may be performed in-office, in physical therapy, or trained for home use.

Treatment variablesProtocols vary by location (vaginal, rectal, chair), stimulus frequency/amplitude, session duration, treatments per day/week, and overall treatment course.

Intended physiologic effectsAims to activate pelvic floor musculature to improve urethral closure and to promote reinnervation and strengthening of pelvic floor muscles depending on incontinence etiology.

Investigational (definition used in this policy)

Revision History

2007-06-12revision

Policy updated with literature review; no change in policy statement noted in history records.

2008-04-11revision

Policy replaced/updated as recorded in history entries.

2014-09-16administrative

Related policies updated and an archived related policy (2.01.527) removed.

Policy Summary

PayerPremera Bluecross

PolicyPelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence

Policy CodePolicy 1.01.17

Change TypeReinstated and revised

Effective DateSep 4, 2026

Last ReviewMay 12, 2026

Next Review Date

Key ActionSubmit prior authorization when proposing non-implantable pelvic floor stimulators billed with CPT 53899 or HCPCS E0740 and document prior conservative treatments.

SourceLink

On This Page

If no specific CPT exists for the service, bill CPT 53899 with supporting documentation
HCPCS E0740 may be used for incontinence treatment systems / pelvic floor stimulators

Documentation Required

Medicare National Coverage Requirements

Medicare National Coverage (NCD 230.8) requires a documented trial of pelvic muscle exercise (PME) training prior to coverage of non-implantable pelvic floor electrical stimulation for stress and/or urge urinary incontinence in cognitively intact patients. Although the NCD addresses urinary incontinence, it does not mention fecal incontinence. Providers should document PME trial results when seeking consideration under Medicare rules.

Covered under Medicare only when there is a documented trial of PME training and the patient is cognitively intact
NCD addresses stress and/or urge urinary incontinence; fecal incontinence is not specified

Step Therapy

Step therapy: No step therapy protocol beyond conservative management and PME trial (as noted by Medicare NCD) is specified in this policy. Providers should follow plan-specific benefit rules; if a payer requires additional stepwise treatments, that will be enforced through prior authorization review.

No additional step therapy requirements described in this policy segment
Document prior conservative treatments (e.g., PME training) in authorization requests

Denial Risk

Investigational Therapy — Denial Risk

Denial risk: Electrical or magnetic stimulation of the pelvic floor muscles for treatment of urinary or fecal incontinence is considered investigational per this policy and may be denied. Providers submitting prior authorization requests should include clinical evidence supporting medical necessity; absence of such evidence may lead to denial.

Therapy is considered investigational for both urinary and fecal incontinence
Requests for coverage may be denied as not medically necessary

Policy usage of term"Investigational" is used to indicate that electrical or magnetic stimulation of the pelvic floor muscles for treatment of urinary or fecal incontinence is considered not established as medically necessary by the payer.

Coverage implicationTherapies classified as investigational are considered not medically necessary for urinary or fecal incontinence and may be denied for that indication.

ScopeThe investigational designation in this policy applies to both electrical and magnetic PFS modalities (examples include extracorporeal magnetic chairs and vaginal/rectal probes).

Policy change notePolicy was reinstated from archive (approved May 12, 2026; effective for dates of service on or after September 4, 2026) and restates the investigational classification after literature review through July 7, 2025.

2015-04-17administrative

Related policies updated and an archived related policy (7.01.553) removed.

2015-07-14archive

Policy archived; low review volume and low-cost procedure noted.

2026-06-01reinstatementLatest

Policy reinstated from archive status (approved May 12, 2026) with 90-day provider notification; policy updated with literature review through July 7, 2025, and an investigational stance for electrical or magnetic pelvic floor stimulation reaffirmed; effective for dates of service on or after 2026-09-04.