Levator Syndrome Treatments
AETNA-CPB-0679
Aetna covers HVPGS and biofeedback (CPT 97014, 97032; HCPCS E0746) for refractory levator syndrome (ICD‑10 K59.4, K62.89) only when no neurological cause is found, prior conservative treatments (high‑fiber diet, stopping constipating/diarrhea‑causing drugs, perineal exercises, rectal massage, warm baths, and drug therapy) have failed, and anorectal exam/manometry/radiology/endoscopy show no underlying disease; more than three 60‑minute sessions over a 10‑day period are not medically necessary. Electrogalvanic stimulators for home use, HVPGS when criteria aren’t met, botulinum toxin, pudendal nerve injections, sacral nerve stimulation, and numerous related injection/implantable device and J/HCPCS/CPT codes (e.g., CPT 64430, 64630, 64561, 64575; E0745, L8680–L8689; various J‑codes) are considered experimental/investigational or not covered.
"Aetna considers biofeedback medically necessary for members with refractory levator syndrome when criteria listed above are met. (See CPB 0132 - Biofeedback)."