Urinary incontinence therapy consists of various behavioral, exercises, and physical medicine techniques designed to alleviate urinary incontinence by enabling the patient to gain voluntary control over the discharge of urine. These techniques include behavioral training, pelvic muscle exercises (PME) such as the Kegel exercise, and the use of vaginal weights, biofeedback and electrical stimulation of the pelvic floor. These techniques may be the first choice in treatment options before pharmacological or surgical treatments are undertaken.
Urinary incontinence therapy may be considered medically necessary when ALL of the following are met.
The following behavioral and therapeutic approaches may be considered medically necessary for the non-surgical/non-pharmacological treatment of UI:
Urinary continence therapy not meeting the criteria as indicated in this policy is considered not medically necessary.
90901 |
90912 |
90913 |
97530 |
99211 |
99213 |
99214 |
99215 |
S9002 |
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Non-implantable pelvic floor electrical stimulators
Non-implantable pelvic floor electrical stimulators may be considered medically necessary for the treatment of stress and/or urge urinary incontinence when ALL of the following conditions are met;
· Individual is cognitively intact; and
· Individual has failed a documented trial of pelvic muscle exercise (PME) training.
Note: A failed trial of PME training is defined as no clinically significant improvement in urinary continence after completing four weeks of an ordered plan of pelvic muscle exercises designed to increase periurethral muscle
Non-implantable pelvic floor electrical stimulators not meeting the criteria as indicated in this policy are considered not medically necessary.
97032 |
E0740 |
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Mechanical/hydraulic incontinence aids
A pessary, a plastic device that fits into the vagina to help support the uterus and bladder, may be considered medically necessary for the treatment of women with stress or mixed UI, and for the treatment of pelvic organ (uterine) prolapse.
Mechanical or hydraulic incontinence control devices for the management of urinary incontinence are covered for individuals with permanent anatomic and neurologic dysfunctions of the bladder (e.g., artificial sphincter). This class of devices achieves control of urination by compression of the urethra.
All other mechanical/hydraulic incontinence aids not meeting the criteria as indicated in this policy, are considered experimental and investigational and therefore non-covered as the safety and/or effectiveness cannot be established by the available peer-reviewed literature.
57160 |
53445 |
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Extracorporeal Magnetic Innervation
Extracorporeal magnetic innervation (ExMI™) treatment is considered experimental/investigational and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
53899 |
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Refer to Medical Policy S-131, Sacral Nerve Neuromodulation/Stimulation, for additional information.
Refer to Medical Policy Z-75, Posterior Tibial Nerve Stimulation, for additional information.
Covered Diagnosis Codes for Procedure code E0740
N39.3 |
N39.41 |
N39.46 |
N39.490 |
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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract, and subject to the applicable laws of your state.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you need these services, contact the Civil Rights Coordinator.
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
