E0740, Non-implanted pelvic floor electrical stimulator, complete system
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Use validated outcome measures to document whether a condition improves or worsens
- Document net health outcome including length of life, quality of life, and ability to function, and record benefits and harms
- Clinical outcome measures focusing on reduction in symptoms (e.g., number of incontinence episodes) and improvements in quality of life.
- Electrical PFS therapy is generally continued for 6 to 8 weeks (expected treatment duration reported in studies).
Key Coverage Criteria
- Pelvic floor stimulation for treatment of urinary incontinence.
- Pelvic floor stimulation for treatment of fecal (bowel) incontinence.
- Electrical stimulation (including vaginal or rectal probe or extracorporeal magnetic pulses) to activate pelvic floor musculature and improve urethral closure via pudendal nerve stimulation.
- Therapeutic stimulation to enhance reinnervation of partially denervated urethral and pelvic floor musculature.
- Detrusor instability (urge urinary incontinence)
- Stress urinary incontinence
10 Active Policies
DME101.037, Pelvic Floor Stimulation as a Treatment of Urinary or Fecal Incontinence
MED201.030, Sexual Dysfunctions, Assessment and Treatment
BCBSIL-DME101.037, Pelvic Floor Stimulation as a Treatment of Urinary or Fecal Incontinence
BCBSIL-MED201.030, Sexual Dysfunctions, Assessment and Treatment
BCBSMT-DME101.037, Pelvic Floor Stimulation as a Treatment of Urinary or Fecal Incontinence
Related Codes
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