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 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.

• 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

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

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