|Highmark Commercial Medical Policy - Pennsylvania|
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 circumstances may warrant individual consideration, based on review of applicable medical records.
Urinary incontinence therapy is covered under the following conditions.
Patients with a form of urinary incontinence (UI) should undergo a basic evaluation that includes a patient history, physical examination, estimation of post-void residual (PVR) volume and urinalysis. This evaluation should demonstrate the existence of the following forms of UI:
The following behavioral and therapeutic approaches are generally recognized as effective for the non-surgical/non-pharmacological treatment of UI:
Bladder Retraining - This behavioral approach is used to help the patient retrain their bladder by educating the patient about the physiology and pathophysiology of their lower urinary tract. This technique teaches the patient how to establish a set voiding schedule by resisting the sensation of bladder urgency, postponing voiding, and urinating during scheduled times as opposed to urinating immediately upon the sensation of urgency.
Habit Training or Timed Voiding - Habit training differs from bladder retraining in that the patient is not instructed to delay voiding or resist the urge to urinate. The goal of this approach is to keep the patient dry by directing the patient to void at regular intervals by matching their "natural" voiding schedule. For example: A patient's voiding pattern is monitored to determine when they void most frequently. The patient is then trained to void at those times before an episode of incontinence occurs.
PME/Kegel - Pelvic muscle exercises (a.k.a., Kegel exercises) improve urethral resistance by actively using and flexing various muscles associated with voluntary urinary retention and voiding. This type of exercise program is generally individualized and should be tailored to enhance pelvic muscle tone progressively based on the patient's needs and abilities. PME/Kegel exercises are often augmented by the use of biofeedback, electrical stimulation of the pelvic floor, or the use of vaginal weights.
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. Non-implantable pelvic floor electrical stimulators for other than stress or urge urinary incontinence will be denied as not medically necessary.
In order for non-implantable pelvic floor electrical stimulators to be medically necessary, patients must be cognitively intact and have failed a documented trial of pelvic muscle exercise (PME) training. 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 strength.
Mechanical/hydraulic incontinence aids
Mechanical/hydraulic incontinence aids are covered for patients with permanent anatomic and neurological dysfunctions of the bladder. All other indications are considered non-covered.
Urethral sphincter is covered for patients with urinary incontinence consequent to permanent and neurological dysfunctions of the bladder. All other indications are considered non-covered.
Electrical Devices (Home Use)
Electrical devices for home use by patients for pelvic floor stimulation are covered.
Extracorporeal Magnetic Innervation
Extracorporeal magnetic innervation (ExMI™) treatment is considered experimental/investigational. The long-term efficacy of this treatment, as well as its acceptance within the medical community, has not been proven.
Stress UI Treatments and Duration
Urge UI Treatments and Duration
Mixed UI Therapy and Duration
The following are patient contraindication criteria where behavioral training techniques and/or exercise programs are not usually recommended:
Patients who are "soon" candidates for pelvic surgery
Patients must be able to understand and perform the training, retraining and/or exercises prescribed to benefit from UI therapies. As with all therapy programs, the duration and frequency of treatment will vary from patient to patient. Requests for additional urinary incontinence therapy sessions should be reviewed on an individual consideration basis by a Medical Director after review of treatment plan information from the provider.
Additionally, coverage for in-patient services is not available if urinary incontinence was the sole reason for the hospitalization.
Coding Information for UI Therapy Services
Experimental/Investigational (E/I) services are not covered regardless of place of service.
Urinary Incontinence Therapy is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.
Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
A network provider can bill the member for the non-covered service.
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.
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.
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.
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.