Medical Policy: 02.01.27 
Original Effective Date: November 1995 
Reviewed: June 2016 
Revised: June 2016 


Benefit Application:

Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary based on contract, and individual member benefits must be verified. Wellmark determines medical necessity only if the benefit exists and no contract exclusions are applicable. This medical policy may not apply to FEP. Benefits are determined by the Federal Employee Program.

This Medical Policy document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy will be reviewed regularly and be updated as scientific and medical literature becomes available.


Description:

Urinary incontinence is defined as the involuntary loss of urine, or the inability to hold urine. It is a common condition affecting both men and women. There are several types, such as stress and urge incontinence, detrusor instability, etc. Many women experience this after childbirth and with increasing age due to muscle weakness. Many men experience this along with prostate problems.

 

There are different types of urinary incontinence. This includes stress incontinence, urge incontinence, mixed incontinence, overflow incontinence, functional incontinence, urinary retention, neurogenic bladder, urinary fistula, and psychogenic incontinence.

 

There are various treatment options available, such as conservative, surgical procedures and supportive devices. Examples of these various treatment options are listed below;

  • Conservative: Includes medical treatment, pelvic floor rehabilitation, Kegel exercises and chronic catheterization.  The American Urogynecologic Society recommends a minimum of three months conservative treatment.
  • Surgical Procedures: Include, but are not limited to, periurethral bulking agents, augmentation cystoplasty, bladder denervation or detrusor myomectomy, enterocystoplasty, bladder diversion, artificial urinary sphincter and cystectomy. These may not be considered first line treatments for most patients and other conservative measures may be considered first.
  • Other measures and supportive devices for the management of urinary incontinence: Include intermittent catheterization, indwelling urethral catheterization, suprapubic catheters, external collection systems, urethral insert devices, penile compression device, pelvic organ support devices, sling systems (MiniArcTM ) and absorbant garments.
  • Pelvic Floor Stimulation (PFS): It involves the electrical stimulation of the pelvic floor muscles using a probe wired to a device controlling the electrical stimulation, or more recently, extracorporeal pulsed magnetic innervation. It is believed that electric or magnetic stimulation leads to PFS, which in turn stimulates the pudendal nerve to improve urethral closure by activating the pelvic musculature by enhancing the process of re-innervation. PFS is an off-label use for electrical stimulation devices.
  • Posterior tibial nerve stimulation (PTNS) The procedure for PTNS consists of the insertion of a needle above the medial malleolus into the posterior tibial nerve followed by the application of low voltage (10mA, 1-10 Hz frequency) electrical stimulation that produces sensory and motor responses (i.e., a tickling sensation and plantar flexion or fanning of all toes). Noninvasive PTNS has also been delivered with surface electrodes.

Artificial Urinary Sphincter
The artificial urinary sphincter (AUS) is an externally controlled urethral occlusion device.  The transfer of fluid within the device is controlled by a pressure-regulating balloon placed extraperitoneally in the individual's pelvis or abdominal cavity and a control pump placed in a subcutaneous pocket in the scrotum.  Squeezing of the pump allows fluid within the closed-loop system to be transferred from the cuff to the balloon.  It takes a few minutes before the cuff re-inflates automatically to the preset level, allowing the urethra to remain open for voiding.  The valve then automatically re-tightens several minutes later which closes the urethra, thereby enabling control of urine flow and continence to be achieved.

 

The artificial urinary sphincter (AUS) is the gold standard of treatment for male urinary incontinence following prostate surgery. It has withstood the test of time, being unsurpassed by any other device for decades. The AUS is particularly effective for the more severe type of male urinary incontinence, where circumferential compression of the urethra is required.

 

Transvaginal and transurethral radiofrequency energy
The Renessa® procedure) induces collagen denaturation in the urethra with a specially designed 4 needle radiofrequency probe. Transurethral treatment changes the collagen at microscopic sites targeted within the bladder neck and areas within the urethral submucosa. The low-level RF energy is believed to strengthen the sphincter without destroying the tissue, by heating only small areas around the probe tip to a specified temperature at which collagen begins the denaturation process.


Prior Approval:

 

Not applicable


Policy:

The following urinary incontinence treatments and devices may be considered medically necessary when the following conditions have been met:

  • Periurethral bulking agents using cross-linked collagen, carbon-coated spheres, calcium hydroxylapatite, or polydimethylsiloxane  marketed under the trade names Durasphere®, Coaptite®, and Macroplastique®  respectively, may be considered medically necessary when the following criteria have been met:

    • The patient has been diagnosed with stress incontinence due to intrinsic sphincter weakness, or due to post traumatic or surgical injury, AND
    • The patient has shown no improvement from conservative measures.
    • If collagen implant (Contigen) is used, a skin test is performed about a month prior to the implant to ensure that no hypersensitivity exists
    • The only FDA approved product for the use in men is Contigen
    • Up to five injection treatments may be considered medically necessary, beyond that, the patient would be considered a treatment failure and further treatment would be considered not medically necessary.
    • The treatment of types of incontinence other than stress incontinence, with periurethral bulking agents¸is considered investigational Based upon literature, urethral bulking agents when used in the treatment of other types of urinary incontinence (e.g., urinary retention with overflow incontinence, functional incontinence, neurogenic bladder dysfunction, urinary fistulas and psychogenic incontinence), as yet, have not demonstrated a benefit to patient.
  • Artificial Urinary Sphincter
    • Implantation of an artificial urinary sphincter device is considered medically necessary in male adults following prostate surgery to treat urinary incontinence due to reduced outlet resistance (Intrinsic Sphincter Deficiency [ISD]) when the symptoms of incontinence have been refractory to at least 6 months of conservative medical treatment.
    • Artificial urinary sphincter implantation is not considered first-line treatment of refractory incontinence in male  adults following prostate surgery.  Examples of first-line conservative medical treatment may include one or more of the following: behavioral therapy, pharmacologic treatments, and intermittent self-catheterization.
    • Implantation of an artificial urinary sphincter device is considered not medically necessary for all other indications including, but not limited to:
      • Treatment of intrinsic sphincter deficiency in women and children whose incontinence has been refractory to conservative medical treatment or other  surgical treatments; and
      • Treatment of intrinsic sphincter deficiency in men who have not undergone prostate surgery.
  • Subureteric injection of dextranomer/hyaluronic acid copolymer (Deflux) Deflux® is a gel-like liquid containing complex sugars, packaged in a syringe. It is used to treat children who have vesicoureteral reflux, an abnormal condition in which urine flows backwards from the bladder to the kidneys. 
    • Indications include treatment of children with vesicoureteral reflux (VUR) grades II-IV. All other indications are considered investigational.

The following treatments and devices are considered investigational for the treatment of urinary incontinence/urinary dysfunction:

  • Biofeedback is considered investigational, since there is no evidence that this is more effective than pelvic muscle exercises, i.e. Kegel exercises.
  • Vaginal weight training with specially designed weights (cones) is considered investigational.
  • Pelvic floor stimulation by any method, electrical or magnetic, is considered investigational.
  • Periurethral bulking agents other than those listed in the policy section above, including, but not limited to, Teflon®, autologous ear chondrocytes and autologous fat tissue are all considered investigational.
  • Transvaginal and transurethral radiofrequency energy therapies for bladder neck suspension, including, but not limited to, the Renessa® System, and the SURx Radiofrequency Bladder Neck Suspension System are all considered investigational.
  • Posterior tibial nerve stimulation is considered investigational for all indications, including but not limited to: urinary frequency, urgency, incontinence, and retention in the treatment of urinary dysfunction.
  • The Neocontrol system, which uses extracorporeal magnetic innervation (ExMI) is considered  investigational because its effectiveness has not been established.

Procedure Codes and Billing Guidelines:

  • To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.
  • L8603  Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies
  • L8604  Injectable bulking agent, dextranomer/hyaluronic acid copolymer implant, urinary tract, 1 ml, includes shipping and necessary supplies
  • L8606  Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies
  • E0740  Incontinence treatment system, pelvic floor stimulator, monitor, sensor, and/or trainer
  • E0746  Electromyography (EMG), biofeedback device
  • 0438T  Transperineal placement of biodegradable material, peri-prostatic (via   needle), single or multiple, includes image guidance
  • 51715  Endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck
  • 53445  Insertion of inflatable urethral/bladder neck sphincter, including placement of pump, reservoir, and cuff
  • 53446  Removal of inflatable urethral/bladder neck sphincter, including pump, reservoir, and cuff
  • 53447  Removal and replacement of inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff at the same operative session
  • 53449  Repair of inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff
  • 53860 T ransurethral, radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence
  • 64566  Posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming
  • 90911  Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry
  • 97039  Unlisted modality (specify type and time if constant attendance)
  • 53899  Unlisted procedure, urinary system (specifically for ExMi)
  • C1815  Prosthesis, urinary sphincter (implantable)
  • 97014  Application of a modality to 1 or more areas; electrical stimulation (unattended)
  • 97032  Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes

Selected References:

  • Galloway. N, El-Galley R, Appell R et al. Extracorporeal Magnetic Innervation Therapy for Stress Urinary Incontinence. Urology 1999;53:1108-11
  • Bo K, Talseth T. Change in Urethral Pressure During Voluntary Pelvic Floor Muscle Contraction and Vaginal Electrical Stimulation. International Urogynecology Journal and Pelvic floor dysfunction 1997; 8:3-7. 
  • Choe JM, Staskin DDR,  Clinical usefulness of urinary control urethral insert devices International Urogynecology Journal and Pelvic floor dysfunction 1997; 8:307-313.
  • Gallo ML, Hancock R, Davila W. Clinical experience with a balloon-tipped urethral insert for stress urinary incontinence. Journal of Wound, Ostomy and Continence Nurses Society 1997:24:51-57.
  • TEC policy 7.01.19 Periurethral bulking agents for the treatment of urinary incontinence.
  • Dmochowski RR. Radiofrequency bladder neck suspension for the treatment of genuine stress urinary incontinence.  Curr Urol Rep. 2002 Oct;3(5):378-81. Review.
  • Ross JW, Galen DI, et al. A prospective multisite study of radiofrequency bipolar energy for treatment of genuine stress incontinence. J Am Assoc Gynecol Laparosc. 2002 Nov;9(4):493-9.
  • ECRI. Implantable Sacral Nerve Stimulator for Urinary Dysfunction. Plymouth Meeting (PA): ECRI Health Technology Information ServiceExternal Site 2006 August 17. 8p. (ECRI Hotline Response).
  • ECRI. Injectable Urethral Bulking Agents for the Treatment of Urinary Stress Incontinence. Plymouth Meeting (PA):  ECRI Health Technology Information ServiceExternal Site 2006 September 22. 11p. (ECRI Hotline Response).
  • ECRI. Sling Systems for Female Urinary Stress Incontinence. Plymouth Meeting (PA):  ECRI Health Technology Information ServiceExternal Site 2006 October 25. 13p. (ECRI Hotline Response).
  • ECRI. Nonsurgical, Transurethral Radiofrequency Collagen Denaturation for Female Stress Urinary Incontinence. Plymouth Meeting (PA):ECRI Health Technology Information ServiceExternal Site 2007 August 10. 6p. (ECRI Hotline Response).
  • Elser, DM, Mitchell, GK, Miklos, JR, Nickell, KG, Cline, K, Winkler, H, and Wells, WG. Nonsurgical transurethral collagen denaturation for stress urinary incontinence in women: 12-month results from a prospective long-term study. J Minim Invasive Gynecol. 2009;16(1):56-62.
  • Davila, GW. Nonsurgical outpatient therapies for the management of female stress urinary incontinence: long-term effectiveness and durability. Adv Urol. 2011;2011:176498.
  • Elser DM, Mitchell GK, Miklos JR, et al. Nonsurgical transurethral collagen denaturation for stress urinary incontinence in women: 18-month results from a prospective long-term study. Neurourol Urodyn. 2010 Nov;29(8):1424-8.
  • ECRI Health Technology Information ServiceExternal Site Nonsurgical, Transurethral Radiofrequency Collagen Denaturation for Female Stress Urinary Incontinence. Plymouth Meeting (PA). 2010 Aug 24. (ECRI Hotline Service)
  • Lucas MG, Bosch RJ, Burkhard FC, et al. EAU Guidelines on Surgical Treatment of Urinary Incontinence. Eur Urol. 2012 Sep 17. [Epub ahead of print]
  • Shamliyan T, Wyman J, Kane RL. Nonsurgical Treatments for Urinary Incontinece in Adult Women: Diagnosis and Comparative Effectiveness. Pub. No. 11(12)-EHC074-EF. Rockville (MD): Agency for Healthcare Research and Quality (US). Comparative Effectiveness Review; April 2012.
  • National Institute for Health and Clinical ExcellenceExternal Site (NICE). Urinary incontinence in neurological disease. Clinical guideline 148; August 2012.
  • Ghoniem GM & Miller CJ. A systematic review and meta-analysis of Macroplastique for treating female stress urinary incontinence. Int Urogynecol J. 2012 Jun 15. [Epub ahead of print]
  • Pradhan A, Jain P, Latthe PM. Effectiveness of midurethral slings in recurrent stress urinary incontinence: a systematic review and meta-analysis. Int Urogynecol J. 2012 Jul;23(7):831-41.
  • Monga AK, Tracey MR, Subbaroyan J. A systematic review of clinical studies of electrical stimulation for treatment of lower urinary tract dysfunction. Int Urogynecol J. 2012 Aug;23(8):993-1005.
  • Greer JA, Smith AL, Arya LA. Pelvic floor muscle training for urgency urinary incontinence in women: a systematic review. Int Urogynecol J. 2012 Jun;23(6):687-97.
  • Gormley EA, Lightner DJ, Burgio KL, et al. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. 2012 May. 36 p.
  • Agency for Healthcare Research and Quality (AHRQ). Nonsurgical Treatments for Urinary Incontinece in Adult Women: Diagnosis and Comparative Effectiveness. Pub. No. 11(12)-EHC074-EF. Prepared by Minnesota Evidence-based Practice Center, Minneapolis MN; April 2012.
  • ECRI. Posterior Tibial Nerve Stimulation for Treating Urge Incontinence. Plymouth Meeting (PA): ECRI Health Technology Information ServiceExternal Site 3/20/12.[Hotling Response].
  • Deflux-product insertExternal Site Oceana Therapeutics. Accessed 9/16/13.
  • Committee on Gynecologic Practice, guideline recommendation Nuber 603. June 2014.
  • U.S. Food and Drug AdministrationExternal Site (FDA). Center for Devices and Radiological Health (CDRH). 510(k) Summary of Safety and Effectiveness. AMS Sphincter 800™ Urinary Prosthesis. No. P000053. Rockville, MD: FDA. June 14, 2001.
  • Petero VG Jr, Diokno AC. Comparison of the long-term outcomes between incontinent men and women treated with artificial urinary sphincter. J Urol. 2006; 175(2):605-609.
  • Islah M, Cho SY, Son H. The current role of the artificial urinary sphincter in male and female urinary incontinence. World J Mens HealthExternal Site 2013; 31(1):21-30.
  • O'Connor RC, Nanigian DK, Patel BN, et al. Artificial urinary sphincter placement in elderly men. Urology. 2007 Jan; 69(1): 126-8. 
  • Sand, PK., Owens, GM., Black, EJ., Anderson, LH., Martinson, MS. Cost=effectiveness of radiofrequency microremodeling for stress urinary incontinence. Int Urogynecol. 2014; 25(4): 517-23.
  • Lukban, JC. Transureethral radiofrequency collagen denaturation for treatment of female stress urinary incontinence: a review of the literature and clinical recommendations. Obstet Gynecol Int. 2012.
  • Shamliyan T, Wyman J, Kane RL. Nonsurgical Treatments for Urinary Incontinence in Adult Women: Diagnosis and Comparative Effectiveness. Comparative Effectiveness Review No. 36. (Prepared by the University of Minnesota Evidence-based Practice Center under Contract No. HHSA 290-2007-10064-I.) AHRQ Publication No. 11(12)-EHC074-EF. Rockville, MD. Agency for Healthcare Research and Quality. April 2012

Policy History:

  • June 2016 - Annual review, Policy revised
  • July 2015 - Annual review, Policy revised
  • August 2014 - Annual review, Policy revised
  • May 2014 - Policy review, Policy revised
  • September 2013 - Annual review, Policy renewed
  • October 2012 - Annual review, Policy renewed
  • October 2011 - Annual review, Policy renewed
  • September 2010 - Annual review, Policy renewed

Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc.   They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.

*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.