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:

• Stress Incontinence (female and male) - Leakage of urine as a result of coughing, straining, sneezing, or some sudden voluntary movement, due to weakness of the muscles around the neck of the bladder, and for females, surrounding the vagina, resulting in an incompetent internal vesical sphincter; or
• Urge Incontinence (female and male) - A strong desire to void urine accompanied by a fear of urine leakage. Urge incontinence can stem from motor urgency related to an overactive detrusor function, or sensory urgency related to vesicourethral hypersensitivity; or
• Mixed Incontinence (female and male) - A combination of stress and urge incontinence. Mixed UI is more common in women, especially older women. Often, one symptom (urge or stress) is more bothersome to the patient than the other. Identifying the most bothersome symptom during the initial patient evaluation is important for targeting the appropriate diagnostic and therapeutic approach; or
• Overflow or Paradoxical Incontinence (female and male) - Since this type of UI does not usually lend itself to effective non-surgical treatment, coverage for behavioral or therapy services related to this diagnosis should be extended on an individual consideration basis after review by a Medical Director.

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

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

• Bladder retraining and habit training are generally recognized as effective for patients with stress UI. These behavioral techniques usually require two sessions with a health care provider, after the initial evaluation to establish bladder control for patients with mild stress UI.
• A pessary can also be a viable option for patients with mild stress UI who cannot, or do not want to attempt bladder retraining or habit training. Pessary placement requires one visit and should include training for pessary maintenance and care.
• PME/Kegel exercise training is the most common form of treatment for stress UI. This training technique usually requires four sessions after the patient evaluation. In moderate to severe cases of stress UI, PME/Kegel is frequently augmented by the use of biofeedback, vaginal weights, and pelvic muscle stimulation. PME/Kegel has also proven effective in the treatment of stress UI in men, including stress UI experienced after prostatectomy. 

Urge UI Treatments and Duration

• Bladder retraining and habit training are generally the first treatment options for patients with urge UI. Generally, a patient with urge UI will require two sessions with a health care provider, after the initial evaluation, to establish bladder control. The ultimate goal in the treatment of urge UI is to reach a point where the patient can go from 2-4 hours, including night, between voids. These techniques should be attempted before the patient undertakes an extensive course of PME/Kegel exercise training. Pharmacotherapy aimed at establishing continence may also be considered before behavioral therapy is attempted with these patients.
• PME/Kegel exercises alone, or augmented with biofeedback, pelvic floor stimulation or vaginal weight training, is generally accepted as effective in the treatment of urge UI patients where bladder retraining or habit training have proven ineffective. This treatment option usually requires four sessions with a health care provider after the initial evaluation and any training/retraining course of treatment. 

Mixed UI Therapy and Duration

• Bladder retraining and habit training have been proven effective for the treatment of mixed UI. When the most pronounced symptom of mixed UI is the urge component, these training/retraining techniques should be the first choice of therapies. Pharmacotherapy for patients with a more pronounced urge component may also be considered before behavioral therapy is attempted with these patients. Generally, patients with mixed UI will need two sessions with a health care provider, after the initial evaluation, to establish bladder control.
• PME/Kegel exercises alone, or augmented with biofeedback; vaginal weights or pelvic muscle stimulation has proven effective for patients with mixed UI, especially where the stress component is more pronounced. This treatment option usually requires four sessions with a health care provider after the initial evaluation.
• Pessary placement can be effective for patients with mixed UI when the stress component of this condition is the most pronounced. Pessary placement requires one visit with a health care provider which should include training for pessary maintenance and care.  

The following are patient contraindication criteria where behavioral training techniques and/or exercise programs are not usually recommended:

• Dementia with significant cognitive dysfunction
• Active urinary tract infections
• Psychological incontinence
• Pharmacological incontinence
• Incontinence due to endocrine disorders
• Severe anatomic and neurogenic urinary tract problems in patients who cannot void voluntarily and/or
• cannot voluntarily control pelvic muscles

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

• The initial evaluation of patients with UI must be performed by a physician and should be reported using the appropriate Evaluation and Management (E&M) code (99211-99215). Itemized billing for diagnostic tests such as urinalysis or PVR is acceptable.
• Bladder retraining, habit training and PME/Kegel exercise training may be billed using the appropriate E&M code or occupational therapy code 97530, which is billed in 15 minute increments. The use of biofeedback and/or vaginal weights in the therapy routine should not be reported separately from the E&M or therapy service.
• Biofeedback should be reported with codes 90901 or 90911.
• Electrical stimulation of the pelvic floor should be reported with code 97032.
• E&M codes and occupational therapy code 97530 should not be reported on the same day by the same provider to report 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.

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• Link to References