470 Form

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Medical Policy Pelvic Floor Stimulation as a Treatment of Urinary Incontinence and Fecal Incontinence Table of Contents
• Policy: Commercial • Coding Information • Information Pertaining to All Policies • Policy: Medicare • Description • References • Authorization Information • Policy History

Policy Number: 470 BCBSA Reference Number: 1.01.17 (For Plan internal use only) Related Policies
• Sacral nerve neuromodulation/stimulation, #153 • Percutaneous Tibial Nerve Stimulation for Voiding Dysfunction, #583 Policy
Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity

Electrical or magnetic stimulation of the pelvic floor muscles (pelvic floor stimulation) as a treatment for urinary incontinence is INVESTIGATIONAL.

Electrical or magnetic stimulation of the pelvic floor muscles (pelvic floor stimulation) as a treatment for fecal incontinence is INVESTIGATIONAL.

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) This is not a covered service. Commercial PPO and Indemnity This is not a covered service. CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member

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Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following codes are included below for informational purposes only; this is not an all-inclusive list.

The following HCPCS code is considered investigational for Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity: HCPCS Codes HCPCS codes: Code Description E0740 Non-implanted pelvic floor electrical stimulator, complete system

Description Pelvic Floor Stimulation Pelvic floor stimulation (PFS) involves electrical stimulation of pelvic floor muscles using either a probe wired to a device for controlling the electrical stimulation or, more recently, extracorporeal electromagnetic (also called magnetic) pulses. Stimulation of the pudendal nerve to activate the pelvic floor musculature may improve urethral closure. In addition, PFS is thought to improve partially denervated urethral and pelvic floor musculature by enhancing the process of reinnervation. Methods of electrical PFS have varied in location (eg, vaginal, rectal), stimulus frequency, stimulus intensity or amplitude, pulse duration, pulse to rest ratio, treatments per day, number of treatment days per week, length of time for each treatment session, and overall time period for device use between clinical and home settings. Variations in the amplitude and frequency of the electrical pulse are used to mimic and stimulate the different physiologic mechanisms of the voiding response, depending on the etiology of the incontinence (ie, either detrusor instability, stress incontinence, or a mixed pattern). Magnetic PFS does not require an internal electrode; instead, patients sit fully clothed on a specialized chair with an embedded magnet.

Patients receiving electrical PFS may undergo treatment in a physician's office or physical therapy facility, or patients may undergo initial training in a physician's office followed by home treatment with a rented or purchased pelvic floor stimulator. Magnetic PFS may be administered in the physician's office.

Summary Description Pelvic floor stimulation is proposed as a nonsurgical treatment option for women and men with urinary or fecal incontinence. This approach involves either electrical stimulation of pelvic floor musculature or extracorporeal pulsed magnetic stimulation.

Summary of Evidence For individuals who have urinary incontinence who receive electrical pelvic floor stimulation (PFS), the evidence includes systematic reviews. Relevant outcomes are symptoms, change in disease status, quality of life, and treatment-related morbidity. Findings from systematic reviews have not found that electrical PFS used to treat urinary incontinence in women consistently improves the net health outcome compared with placebo or other conservative treatments. Moreover, meta-analyses of RCTs have not found a significant benefit of electrical PFS in men with postprostatectomy incontinence compared with a control intervention. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have fecal incontinence who receive electrical PFS, the evidence includes systematic reviews and RCTs. Relevant outcomes are symptoms, change in disease status, quality of life, and treatment-related morbidity. Among the RCTs that have evaluated electrical PFS as a treatment for fecal incontinence, only 1 trial was sham-controlled, and it did not find that electrical stimulation improved the net health outcome. Systematic reviews of RCTs have not found that electrical stimulation is superior to control interventions for treating fecal incontinence. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

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For individuals who have urinary incontinence who receive magnetic PFS, the evidence includes systematic reviews and RCTs. Relevant outcomes are symptoms, change in disease status, quality of life, and treatment-related morbidity. A systematic review of RCTs on magnetic PFS for urinary incontinence in women concluded that the evidence was insufficient due to the following factors: a low number of trials with short-term follow-up, methodologic limitations, as well as heterogeneity in patient populations, interventions, and outcomes reported. One RCT evaluating magnetic stimulation for treating men with postprostatectomy urinary incontinence reported short-term results favoring magnetic PFS; however, the trial was small and lacked a sham comparator. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have fecal incontinence who receive magnetic PFS, no relevant evidence was identified. Relevant outcomes are symptoms, change in disease status, quality of life, and treatment-related morbidity. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome. Policy History Date Action 10/2025 Annual policy review. Policy updated with literature review through July 7, 2025; references added. Policy statements unchanged.
1/2025 Clarified coding information. Transferred E0715 and E0716 to MP 400 Medical Technology Assessment NonCovered Services.
10/2024 Annual policy review. Policy updated with literature review through June 12, 2024; references added. Policy statements unchanged. Clarified coding information. 10/2023 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 10/2022 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 9/2021 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 1/2021 Medicare information removed. See MP #132 Medicare Advantage Management for local coverage determination and national coverage determination reference.
10/2020 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 10/2019 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 10/2018 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 1/2017 Clarified coding information for the 2017 code changes.
11/2016 Annual policy review. New references added. 8/2016 Clarified coding information. 6/2015 Annual policy review. New references added. 9/2014 Annual policy review. New investigational indications described; title changed. Effective 9/1/2014.
5/2013 Annual policy review. New references added. 11/2011- 4/2012 Medical policy ICD 10 remediation: Formatting, editing and coding updates.
No changes to policy statements.
9/2011 Reviewed - Medical Policy Group - Urology and Obstetrics/Gynecology.
No changes to policy statements. 6/2010 Reviewed - Medical Policy Group - Urology and Obstetrics/Gynecology.
No changes to policy statements. 6/2010 Reviewed - Medical Policy Group - Urology and Obstetrics/Gynecology.
No changes to policy statements. 3/2010 Updated to remove information related to biofeedback for urinary incontinence, as this will be separately addressed under Medical Policy, #173, effective 3/2010. 1/2010 Annual policy review. Changes to policy statements.

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6/2009 Reviewed - Medical Policy Group - Urology and Obstetrics/Gynecology.
No changes to policy statements. 6/2009 Annual policy review. No changes to policy statements. 6/2008 Reviewed - Medical Policy Group - Urology and Obstetrics/Gynecology.
No changes to policy statements. 11/2007 Annual policy review. No changes to policy statements. Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines

References

1. Gorina Y, Schappert S, Bercovitz A, et al. Prevalence of incontinence among older americans. Vital Health Stat 3. Jun 2014; (36): 1-33. PMID 24964267
2. Markland AD, Goode PS, Redden DT, et al. Prevalence of urinary incontinence in men: results from the national health and nutrition examination survey. J Urol. Sep 2010; 184(3): 1022-7. PMID 20643440
3. Abdelbary AM, El-Dessoukey AA, Massoud AM, et al. Combined Vaginal Pelvic Floor Electrical Stimulation (PFS) and Local Vaginal Estrogen for Treatment of Overactive Bladder (OAB) in Perimenopausal Females. Randomized Controlled Trial (RCT). Urology. Sep 2015; 86(3): 482-6. PMID 26135813
4. Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Pelvic floor electrical stimulation in the treatment of urinary incontinence in adults. TEC Assessments. 2000;Volume 15:Tab
6. Naidu D, Modi R, Kulkarni M, et al. Intravaginal electrical stimulation of the pelvic floor for women with urinary incontinence - a systematic review of randomised controlled trials. Am J Obstet Gynecol. Mar 20 2025. PMID 40120731
7. Leonardo K, Seno DH, Mirza H, et al. Biofeedback-assisted pelvic floor muscle training and pelvic electrical stimulation in women with overactive bladder: A systematic review and meta-analysis of randomized controlled trials. Neurourol Urodyn. Aug 2022; 41(6): 1258-1269. PMID 35686543
8. Stewart F, Berghmans B, Bø K, et al. Electrical stimulation with non-implanted devices for stress urinary incontinence in women. Cochrane Database Syst Rev. Dec 22 2017; 12(12): CD012390. PMID 29271482
9. Shamliyan T, Wyman J, Kane R. Nonsurgical Treatments for Urinary Incontinence in Adult Women: Diagnosis and Comparative Effectiveness (Comparative Effectiveness Review 36). Rockville, MD: Agency for Healthcare Research and Quality; 2012.
10. Moroni RM, Magnani PS, Haddad JM, et al. Conservative Treatment of Stress Urinary Incontinence: A Systematic Review with Meta-analysis of Randomized Controlled Trials. Rev Bras Ginecol Obstet. Feb 2016; 38(2): 97-111. PMID 26883864
11. Tang G, Liu M, Chen X, et al. Effectiveness of electrical stimulation for treating male urinary incontinence after prostatectomy: a meta-analysis and systematic review. Int J Surg. Jun 27 2025. PMID 40576184
12. Sciarra A, Viscuso P, Arditi A, et al. A biofeedback-guided programme or pelvic floor muscle electric stimulation can improve early recovery of urinary continence after radical prostatectomy: A meta- analysis and systematic review. Int J Clin Pract. Oct 2021; 75(10): e14208. PMID 33811418
13. Berghmans B, Hendriks E, Bernards A, et al. Electrical stimulation with non-implanted electrodes for urinary incontinence in men. Cochrane Database Syst Rev. Jun 06 2013; 2013(6): CD001202. PMID 23740763
14. Johnson EE, Mamoulakis C, Stoniute A, et al. Conservative interventions for managing urinary incontinence after prostate surgery. Cochrane Database Syst Rev. Apr 18 2023; 4(4): CD014799. PMID 37070660

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14. Zhu YP, Yao XD, Zhang SL, et al. Pelvic floor electrical stimulation for postprostatectomy urinary incontinence: a meta-analysis. Urology. Mar 2012; 79(3): 552-5. PMID 22386394
15. Cohen-Zubary N, Gingold-Belfer R, Lambort I, et al. Home electrical stimulation for women with fecal incontinence: a preliminary randomized controlled trial. Int J Colorectal Dis. Apr 2015; 30(4): 521-8. PMID 25619464
16. Norton C, Gibbs A, Kamm MA. Randomized, controlled trial of anal electrical stimulation for fecal incontinence. Dis Colon Rectum. Feb 2006; 49(2): 190-6. PMID 16362803
17. Vonthein R, Heimerl T, Schwandner T, et al. Electrical stimulation and biofeedback for the treatment of fecal incontinence: a systematic review. Int J Colorectal Dis. Nov 2013; 28(11): 1567-77. PMID 23900652
18. Schwandner T, König IR, Heimerl T, et al. Triple target treatment (3T) is more effective than biofeedback alone for anal incontinence: the 3T-AI study. Dis Colon Rectum. Jul 2010; 53(7): 1007-16. PMID 20551752
19. Schwandner T, Hemmelmann C, Heimerl T, et al. Triple-target treatment versus low-frequency electrostimulation for anal incontinence: a randomized, controlled trial. Dtsch Arztebl Int. Sep 2011; 108(39): 653-60. PMID 22013492
20. Hosker G, Cody JD, Norton CC. Electrical stimulation for faecal incontinence in adults. Cochrane Database Syst Rev. Jul 18 2007; 2007(3): CD001310. PMID 17636665
21. Lim R, Lee SW, Tan PY, et al. Efficacy of electromagnetic therapy for urinary incontinence: A systematic review. Neurourol Urodyn. Nov 2015; 34(8): 713-22. PMID 25251335
22. Lim R, Liong ML, Leong WS, et al. Pulsed Magnetic Stimulation for Stress Urinary Incontinence: 1-Year Followup Results. J Urol. May 2017; 197(5): 1302-1308. PMID 27871927
23. Unal B, Sarsan A, Yıldız N, et al. Efficacy of Magnetic Stimulation in Men With Urinary Incontinence After Radical Prostatectomy: A Randomized, Quadruple-Blind, Sham-Controlled Clinical Trial. Neurourol Urodyn. Jun 2025; 44(5): 1140-1148. PMID 40223765
24. Wald A, Bharucha AE, Limketkai B, et al. ACG Clinical Guidelines: Management of Benign Anorectal Disorders. Am J Gastroenterol. Oct 01 2021; 116(10): 1987-2008. PMID 34618700
25. Bordeianou LG, Thorsen AJ, Keller DS, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Fecal Incontinence. Dis Colon Rectum. May 01 2023; 66(5): 647-661. PMID 40324433
26. Cameron AP, Chung DE, Dielubanza EJ, et al. The AUA/SUFU Guideline on the Diagnosis and Treatment of Idiopathic Overactive Bladder. J Urol. Jul 2024; 212(1): 11-20. PMID 38651651
27. Sandhu JS, Breyer B, Comiter C, et al. Incontinence after Prostate Treatment: AUA/SUFU Guideline. J Urol. Aug 2019; 202(2): 369-378. PMID 31059663
28. Breyer BN, Kim SK, Kirkby E, et al. Updates to Incontinence After Prostate Treatment: AUA/GURS/SUFU Guideline (2024). J Urol. Oct 2024; 212(4): 531-538. PMID 38934789
29. National Institute for Health and Care Excellence (NICE) Guideline. Urinary Incontinence and Pelvic Organ Prolapse in Women: Management. NICE Guideline. 2019. https://www.nice.org.uk/guidance/ng123. Accessed July 7, 2025.
30. National Institute for Health and Care Excellence (NICE). Faecal incontinence in adults: management [CG49]. 2007; https://www.nice.org.uk/guidance/cg49. Accessed July 8, 2025
31. Centers for Medicare & Medicaid Services (CMS). CMS Manual System: Pub 100-03 Medicare National Coverage Determinations; Transmittal 48. 2006; https://www.cms.gov/medicare-coverage- database/details/ncd-details.aspx?NCDId=231. Accessed July 8, 2025.