SURG.00010 Treatments for Urinary Incontinence

This policy addresses treatments for urinary incontinence, focusing on periurethral bulking agent injections and select devices/therapies. Periurethral bulking injection is medically necessary for stress urinary incontinence when due to trauma/injury, or when symptoms persist after adequate conservative therapy and are caused by intrinsic sphincter deficiency or urethral hypermobility with abdominal leak point pressure <100 cm H2O; otherwise, bulking injections and artificial urinary sphincter implantation/revision/removal are not medically necessary. Endovaginal cryogen-cooled monopolar radiofrequency remodeling, inFlow intraurethral valve-pump implantation, ProACT adjustable continence therapy, and vaginal weight training (cones) are investigational and not covered.

"Injection of periurethral bulking agents is consideredmedically necessarywhen the individual has stress urinary incontinence (SUI) meeting one the following two criteria (A or B):"