Anthem Blue Cross Connecticut SURG.00010 Treatments for Urinary Incontinence Form

This document addresses the following treatments for urinary incontinence:

• Vaginal weight training;
• Injection of periurethral bulking agents;
• Transvaginal radiofrequency bladder neck suspension; 
• Transurethral radiofrequency energy collagen micro-remodeling;
• Artificial urinary sphincter devices;
• Intraurethral valve-pump implantation;
• Adjustable balloon system implantation;
• Endovaginal cryogen-cooled, monopolar radiofrequency remodeling.

Note: Please see the following related document(s) for additional information:

• MED.00125 Biofeedback and Neurofeedback
• CG-SURG-08 Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury
• CG-SURG-95 Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention

Position Statement

Medically Necessary:

Injection of periurethral bulking agents is considered medically necessary when the individual has stress urinary incontinence (SUI) meeting one the following two criteria (A or B):

1. The incontinence is due to trauma or injury; or
2. Both of the following are true (1 and 2):
   1. The incontinence persists despite conservative treatment for at least a sufficient duration to fully assess treatment effect*; and
   2. One of the following is true:
      1. The incontinence is caused by intrinsic sphincter deficiency (ISD), or
      2. The incontinence is due to urethral hypermobility in individuals with abdominal leak point less than 100 cm H₂O.

Implantation of an artificial urinary sphincter device is considered medically necessary in adults following prostate surgery to treat urinary incontinence due to reduced outlet resistance (Intrinsic Sphincter Deficiency [ISD]) when the symptoms of incontinence persist despite conservative treatment for at least a sufficient duration to fully assess treatment effect.*

*Note: The time frame for prior conservative treatment measures (for example, exercises, medication, behavioral therapy) to demonstrate a refractory response is at least 2 months duration, subject to individual variability.

Not Medically Necessary:

Injection of periurethral bulking agents is considered not medically necessary for individuals who do not meet the medically necessary criteria.

Implantation of an artificial urinary sphincter device is considered not medically necessary for individuals who do not meet the medically necessary criteria.

Investigational and Not Medically Necessary:

The following services are considered investigational and not medically necessary as treatments for urinary incontinence:

1. inFlow^™ intraurethral valve-pump implantation;
2. ProACT^™ adjustable continence therapy;
3. Vaginal weight training with specially designed weights (cones);
4. Transvaginal radiofrequency bladder neck suspension;
5. Transurethral radiofrequency energy collagen micro-remodeling;
6. Endovaginal cryogen-cooled, monopolar radiofrequency remodeling.