Pelvic floor stimulation is a nonsurgical treatment for individuals with urinary incontinence. These devices stimulate the pudendal nerve to activate pelvic floor muscles. Pelvic floor electrical stimulation (PFES) is a type of transcutaneous electrical nerve stimulation (TENS) that uses a probe wired to a device that controls the level of stimulation. Magnetic (also called electromagnetic) stimulation delivers pulses using a specialized chair with an embedded magnet.
Several non-implanted PFES devices have been cleared by the U.S. Food and Drug Administration (FDA) to treat urinary incontinence. These include but are not limited to the EmbaGYN®, itouch Sure Pelvic Floor Exerciser, Attain and UROstim™ devices. An extracorporeal pelvic floor magnetic stimulation device, the NeoControl® Pelvic Floor Therapy System was approved by the FDA for treatment of male and female urinary and fecal incontinence.
I. Pelvic Floor Electrical Stimulation
Use of non-implanted pelvic floor electrical stimulation may be considered MEDICALLY NECESSARY AND APPROPRIATE for treatment of non-neurogenic or urge urinary incontinence in patients who have undergone a trial of pelvic muscle exercises for a period of at least four (4) weeks with no significant improvement in incontinence.
II. The following non-implanted pelvic floor stimulation treatments for urinary incontinence are considered EXPERIMENTAL/INVESTIGATIVE due to lack of clinical evidence demonstrating an impact on improved health outcomes:
No additional statements.
Blue Cross and Blue Shield of Minnesota medical policies apply generally to all Blue Cross and Blue Plus plans and products. Benefit plans vary in coverage and some plans may not provide coverage for certain services addressed in the medical policies. When determining coverage, reference the member’s specific benefit plan, including exclusions and limitations.
Medicaid products may provide different coverage for certain services, which may be addressed in different policies. For Minnesota Health Care Program (MHCP) policies, please consult the MHCP Provider Manual website.
Medicare products may provide different coverage for certain services, which may be addressed in different policies. For Medicare National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and/or Local Coverage Articles, please consult CMS, National Government Services, or CGS websites.
Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met.
Blue Cross and Blue Shield of Minnesota reserves the right to revise, update and/or add to its medical policies at any time without notice. Codes listed on this policy are included for informational purposes only and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement.
These guidelines are the proprietary information of Blue Cross and Blue Shield of Minnesota. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Acknowledgements:
CPT® codes copyright American Medical Association® 2023. All rights reserved.
CDT codes copyright American Dental Association® 2023. All rights reserved.
