Question 1

When does Aetna cover Urinary Incontinence (CPT 51726), and what gets it denied?

Accepted Answer

Aetna CPB 0223 covers a range of urinary incontinence treatments — including urodynamic studies, artificial urinary sphincters, bulking-agent injections, sacral nerve stimulation, PTNS, slings/TVT/TOT, pessaries, vaginal cones, urethral inserts, the Renessa procedure, the Cunningham clamp, and intravaginal electrical stimulation — but generally only after conservative management (behavioral therapy, pelvic floor exercises, and pharmacotherapy) has been tried and failed, with implantable devices additionally requiring a successful temporary trial showing at least 50% improvement. Many newer or alternative modalities (e.g., laser/RF for OAB, magnetic stimulation, PRP, stem cell therapy, transcutaneous/subcutaneous tibial nerve stimulators, adjustable balloon devices, and various pelvic-muscle trainer devices) are considered experimental, investigational, or unproven. Coverage criteria include: Multi-channel urodynamic studies are medically necessary when BOTH: (1) member has both symptoms AND physical findings of urinary incontinence/voiding dysfunction (e.g., stress incontinence, overactive bladder, lower urinary tract symptoms); AND (2) the provider is considering performing invasive, potentially morbid or irreversible treatments after conservative management has been tried and failed.; Implantation of an artificial urinary sphincter (AUS) is medically necessary for intrinsic urethral sphincter deficiency when member has ANY ONE of: (a) children with intractable UI due to intrinsic urethral sphincter deficiency who are refractory to behavioral or pharmacological therapies and are unsuitable candidates for other types of surgical procedures; OR (b) members 6 or more months post-prostatectomy who have had no improvement in the severity of UI despite trials of behavioral and/or pharmacological therapies; OR (c) members with epispadias-exstrophy in whom bladder neck reconstruction has failed; OR (d) women with intractable UI who have failed behavioral or pharmacological, and other surgical treatments.; Peri-urethral injection of FDA-cleared bulking agents (e.g., Bulkamid, Coaptite, Contigen, Durasphere, Macroplastique, Uryx) is medically necessary for UI resulting from intrinsic sphincter deficiency that is refractory to conservative management (e.g., Kegel exercises, biofeedback, electrical stimulation, and/or pharmacotherapies). NOTE: members whose incontinence does not improve after 3 treatments with bulking agents are considered treatment failures and are not likely to respond to this therapy.; Implantable sacral nerve stimulator (e.g., Axonics, InterStim) for urge UI or symptoms of urge-frequency is medically necessary when ALL of the following are met: (1) member has experienced urge UI or symptoms of urge-frequency for at least 6 months and the condition has resulted in significant disability; AND (2) pharmacotherapies (i.e., at least 2 different anti-cholinergic drugs, or an anti-cholinergic and a beta-3 adrenergic receptor agonist [mirabegron]) and behavioral treatments (e.g., pelvic floor exercise, biofeedback, timed voids, fluid management) resulted in failure or inadequate response after a 12-week trial, absent a contraindication; AND (3) temporary trial stimulation (basic PNE or advanced Stage 1) provides at least 50% decrease in symptoms.; Implantable sacral nerve stimulator for non-obstructive urinary retention is medically necessary when ALL of the following are met: (1) member has experienced urinary retention for at least 6 months and the condition has resulted in significant disability; AND (2) pharmacotherapies (e.g., alpha blockers and antibiotics for urinary tract infections) as well as intermittent catheterization have failed or are not well-tolerated; AND (3) temporary trial stimulation provides at least 50% decrease in residual urine volume.; Temporary trial stimulation for sacral nerve stimulation is medically necessary for members who meet selection criteria 1 and 2 (the duration/disability and failed-conservative-therapy criteria) for either urge incontinence or non-obstructive urinary retention; no more than 6 total test stimulations are considered medically necessary.; Removal of an implantable sacral nerve stimulator is medically necessary even where the initial implantation/replacement was not indicated.; Vaginal cones are medically necessary when used in combination with a structured pelvic floor muscle exercise (Kegel's exercise) program for the treatment of simple (pure) stress UI.; A pessary (bladder neck support prosthesis) is medically necessary for the treatment of women with stress or mixed UI, and for the treatment of pelvic organ (uterine) prolapse.; Tension-free vaginal tape (TVT) procedure is medically necessary for the treatment of stress UI when women with intractable UI have failed behavioral and/or pharmacological treatments.; Transobturator tape (TOT) procedure is medically necessary for the treatment of stress UI when women with intractable stress UI have failed behavioral and/or pharmacological treatments.; Colposuspension and sling procedures are medically necessary for persons with stress UI that is refractory to conservative management (e.g., pelvic floor muscle training, electrical stimulation, and biofeedback).; Percutaneous tibial nerve stimulation (PTNS) is medically necessary for the treatment of members with idiopathic overactive bladder (urge UI or urge-frequency) when members meet the first 2 criteria listed for implantable sacral nerve stimulators (i.e., at least 6 months of symptoms with significant disability AND failure/inadequate response to pharmacotherapies and behavioral treatments). In general, 12 once-weekly treatments are needed for symptom relief; if the member fails to improve after 12 PTNS treatments, continued treatment is not medically necessary; if the member improves after 12 PTNS treatments, continued monthly treatments are medically necessary as long as the member's symptoms remain improved.; Transurethral radiofrequency therapy (Renessa procedure) is medically necessary for the treatment of stress UI in non-pregnant women who are either not able or not willing to undergo surgery for their condition.; Urethral inserts are medically necessary for the treatment of female stress UI.; A Cunningham clamp is medically necessary for the treatment of post-prostatectomy urinary incontinence in men with stress incontinence and good bladder storage function.; Intravaginal electrical stimulation is medically necessary for women with stress, urgency, or mixed urinary incontinence.; Biofeedback for urinary incontinence is addressed under CPB 0132 - Biofeedback.. Applies to 24 codes: 51726, 51727, 51728, 51729, 51741, 51784, 51785, 53444, 53445, 53446, 53447, 53448, 53449, 51715, 51990, 51992, 57287, 57288, 53440, 53441, 53442, 64561, 64581, 64566. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Documentation of symptom duration and severity (e.g., symptoms present for at least 6 months and resulting in significant disability for sacral nerve stimulation indications).; Documentation of failed/inadequate response to conservative treatments, including specific behavioral therapies and pharmacotherapies tried (e.g., the required 12-week trial of pharmacotherapies and behavioral treatments before sacral nerve stimulation or PTNS).; For sacral nerve stimulation: documentation of temporary trial stimulation results showing at least 50% decrease in symptoms (urge UI/urge-frequency) or at least 50% decrease in residual urine volume (non-obstructive urinary retention).; Documentation of symptoms, physical findings, and prior conservative management for multi-channel urodynamic studies and other invasive treatments. Policy exclusions and limitations: Artificial urinary sphincter (AUS) is considered experimental, investigational, or unproven for all indications other than those listed as medically necessary, because its effectiveness for other indications has not been established.; Magnetically controlled endo-urethral artificial urinary sphincter is not covered (experimental, investigational, or unproven).; Peri-urethral bulking agents are considered experimental/investigational for neurogenic bladder and all other indications not listed as medically necessary.; Peri-urethral bulking agents are contraindicated / not covered for members undergoing or planning desensitization injections to meat products.; Peri-urethral bulking agents are contraindicated / not covered for members with acute cystitis, urethritis, or infection.; Peri-urethral bulking agents are contraindicated / not covered for members with severe allergies (history of anaphylaxis or multiple severe allergies).; Peri-urethral bulking agents are contraindicated / not covered for members with previous pelvic radiation therapy.; Peri-urethral bulking agents are contraindicated / not covered for members with an unstable or noncompliant bladder.; Implantable sacral nerve stimulator is not indicated/covered where incontinence is due to mechanical obstruction such as benign prostatic hypertrophy or urethral stricture.; Implantable sacral nerve stimulator is not indicated/covered for persons with stress incontinence.; Implantable sacral nerve stimulator is not indicated/covered for individuals with neurologic disease origins, such as multiple sclerosis or diabetes with peripheral nerve involvement; it has not been shown to be effective for urinary retention, urinary frequency-urgency syndrome, or urge urinary incontinence due to these causes.; Implantable sacral nerve stimulator is not indicated/covered for individuals who have not demonstrated an appropriate response to temporary trial stimulation or who are unable to operate the neurostimulator.; Bilateral implantation of a permanent sacral nerve stimulator is considered experimental, investigational, or unproven because the effectiveness of bilateral implantation has not been established.; Implantable sacral nerve stimulator is considered experimental, investigational, or unproven for all indications other than those listed as medically necessary.; Implantable sacral nerve stimulator for neurogenic bladder is considered experimental, investigational, or unproven.; Vaginal cones are considered experimental/investigational for indications other than those listed as medically necessary, because effectiveness for other indications has not been established.; Pessary is considered experimental/investigational for indications other than those listed as medically necessary, because effectiveness for other indications has not been established.; Tension-free vaginal tape (TVT) procedure is considered experimental/investigational for indications other than the one listed as medically necessary (except for the treatment of pelvic organ prolapse complicated by stress UI), because effectiveness for other indications has not been established.; Transobturator tape (TOT) procedure is considered experimental/investigational for urge urinary incontinence and other indications, because effectiveness for indications other than the one listed has not been established.; Colposuspension and sling procedures are considered experimental/investigational for indications other than the one listed as medically necessary, because effectiveness for other indications has not been established.; Adjustable retropubic sub-urethral sling is not covered / considered experimental, investigational, or unproven (for stress incontinence).; Percutaneous tibial nerve stimulation (PTNS) is considered experimental/investigational when the medical necessity criteria are not met.; Micro-ablative radiofrequency for treatment of over-active bladder is not covered (experimental, investigational, or unproven).; Urethral inserts are considered experimental/investigational for indications other than the one listed as medically necessary, because effectiveness for other indications has not been established.; Adjustable trans-obturator male system for stress incontinence is considered experimental, investigational, or unproven.; Autologous myoblast transplantation is considered experimental, investigational, or unproven.; Autologous muscle-derived cell therapy is considered experimental, investigational, or unproven.; Bariatric surgery for UI is considered experimental, investigational, or unproven (unless other criteria are met).; Collagen porcine dermis mesh is considered experimental, investigational, or unproven.; Dynamometry for quantification of pelvic floor muscle strength is considered experimental, investigational, or unproven.; Electrical nerve stimulation for male pelvic floor dysfunction is considered experimental, investigational, or unproven.; Electro-acupuncture for neurogenic bladder is considered experimental, investigational, or unproven.; Flyte System (mechanotherapy) for stress UI is considered experimental, investigational, or unproven.; Genetic testing for stress urinary incontinence is considered experimental, investigational, or unproven.; High-intensity focused electromagnetic therapy for stress UI is considered experimental, investigational, or unproven.; Laser therapy (Genityte procedure and FemiLift CO2 laser) is considered experimental, investigational, or unproven.; Magnetic stimulation for stress UI is considered experimental, investigational, or unproven.; Moxibustion for post-stroke UI and stress UI is considered experimental, investigational, or unproven.; Neocontrol System (extracorporeal magnetic innervation) is considered experimental, investigational, or unproven.; Platelet-rich plasma is considered experimental, investigational, or unproven.; Protect PNS System (wireless neuromodulation) for overactive bladder is considered experimental, investigational, or unproven.; Pudendal nerve stimulation is considered experimental, investigational, or unproven.; Radiofrequency micro-remodeling with the SURx System is considered experimental, investigational, or unproven.; Subcutaneous and subfascial tibial nerve stimulation (INTIBIA) is considered experimental, investigational, or unproven.; Subcutaneous tibial nerve stimulation (e.g., eCoin, Altaviva) is considered experimental, investigational, or unproven.; Subfascial tibial nerve stimulation (e.g., BlueWind Revi) is considered experimental, investigational, or unproven.; Stem cell therapy (mesenchymal stem/stromal cells) is considered experimental, investigational, or unproven.; Transcutaneous electrical nerve stimulation (TENS) for overactive bladder is considered experimental, investigational, or unproven.; Transcutaneous tibial nerve stimulation (e.g., Vivally, ZIDA) is considered experimental, investigational, or unproven.; Transperineal implantation of a permanent adjustable balloon continence device (e.g., ACT, ProACT) is considered experimental, investigational, or unproven.; Vibratory perineal stimulation is considered experimental, investigational, or unproven.; Pelvic muscle trainer devices (e.g., Athena, Gyneflex, Kegelmaster) are considered experimental, investigational, or unproven. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Question 2

Does Aetna require prior authorization for Urinary Incontinence?

Accepted Answer

Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Documentation of symptom duration and severity (e.g., symptoms present for at least 6 months and resulting in significant disability for sacral nerve stimulation indications).; Documentation of failed/inadequate response to conservative treatments, including specific behavioral therapies and pharmacotherapies tried (e.g., the required 12-week trial of pharmacotherapies and behavioral treatments before sacral nerve stimulation or PTNS).; For sacral nerve stimulation: documentation of temporary trial stimulation results showing at least 50% decrease in symptoms (urge UI/urge-frequency) or at least 50% decrease in residual urine volume (non-obstructive urinary retention).; Documentation of symptoms, physical findings, and prior conservative management for multi-channel urodynamic studies and other invasive treatments.

Question 3

What does Aetna exclude for Urinary Incontinence?

Accepted Answer

Policy exclusions and limitations: Artificial urinary sphincter (AUS) is considered experimental, investigational, or unproven for all indications other than those listed as medically necessary, because its effectiveness for other indications has not been established.; Magnetically controlled endo-urethral artificial urinary sphincter is not covered (experimental, investigational, or unproven).; Peri-urethral bulking agents are considered experimental/investigational for neurogenic bladder and all other indications not listed as medically necessary.; Peri-urethral bulking agents are contraindicated / not covered for members undergoing or planning desensitization injections to meat products.; Peri-urethral bulking agents are contraindicated / not covered for members with acute cystitis, urethritis, or infection.; Peri-urethral bulking agents are contraindicated / not covered for members with severe allergies (history of anaphylaxis or multiple severe allergies).; Peri-urethral bulking agents are contraindicated / not covered for members with previous pelvic radiation therapy.; Peri-urethral bulking agents are contraindicated / not covered for members with an unstable or noncompliant bladder.; Implantable sacral nerve stimulator is not indicated/covered where incontinence is due to mechanical obstruction such as benign prostatic hypertrophy or urethral stricture.; Implantable sacral nerve stimulator is not indicated/covered for persons with stress incontinence.; Implantable sacral nerve stimulator is not indicated/covered for individuals with neurologic disease origins, such as multiple sclerosis or diabetes with peripheral nerve involvement; it has not been shown to be effective for urinary retention, urinary frequency-urgency syndrome, or urge urinary incontinence due to these causes.; Implantable sacral nerve stimulator is not indicated/covered for individuals who have not demonstrated an appropriate response to temporary trial stimulation or who are unable to operate the neurostimulator.; Bilateral implantation of a permanent sacral nerve stimulator is considered experimental, investigational, or unproven because the effectiveness of bilateral implantation has not been established.; Implantable sacral nerve stimulator is considered experimental, investigational, or unproven for all indications other than those listed as medically necessary.; Implantable sacral nerve stimulator for neurogenic bladder is considered experimental, investigational, or unproven.; Vaginal cones are considered experimental/investigational for indications other than those listed as medically necessary, because effectiveness for other indications has not been established.; Pessary is considered experimental/investigational for indications other than those listed as medically necessary, because effectiveness for other indications has not been established.; Tension-free vaginal tape (TVT) procedure is considered experimental/investigational for indications other than the one listed as medically necessary (except for the treatment of pelvic organ prolapse complicated by stress UI), because effectiveness for other indications has not been established.; Transobturator tape (TOT) procedure is considered experimental/investigational for urge urinary incontinence and other indications, because effectiveness for indications other than the one listed has not been established.; Colposuspension and sling procedures are considered experimental/investigational for indications other than the one listed as medically necessary, because effectiveness for other indications has not been established.; Adjustable retropubic sub-urethral sling is not covered / considered experimental, investigational, or unproven (for stress incontinence).; Percutaneous tibial nerve stimulation (PTNS) is considered experimental/investigational when the medical necessity criteria are not met.; Micro-ablative radiofrequency for treatment of over-active bladder is not covered (experimental, investigational, or unproven).; Urethral inserts are considered experimental/investigational for indications other than the one listed as medically necessary, because effectiveness for other indications has not been established.; Adjustable trans-obturator male system for stress incontinence is considered experimental, investigational, or unproven.; Autologous myoblast transplantation is considered experimental, investigational, or unproven.; Autologous muscle-derived cell therapy is considered experimental, investigational, or unproven.; Bariatric surgery for UI is considered experimental, investigational, or unproven (unless other criteria are met).; Collagen porcine dermis mesh is considered experimental, investigational, or unproven.; Dynamometry for quantification of pelvic floor muscle strength is considered experimental, investigational, or unproven.; Electrical nerve stimulation for male pelvic floor dysfunction is considered experimental, investigational, or unproven.; Electro-acupuncture for neurogenic bladder is considered experimental, investigational, or unproven.; Flyte System (mechanotherapy) for stress UI is considered experimental, investigational, or unproven.; Genetic testing for stress urinary incontinence is considered experimental, investigational, or unproven.; High-intensity focused electromagnetic therapy for stress UI is considered experimental, investigational, or unproven.; Laser therapy (Genityte procedure and FemiLift CO2 laser) is considered experimental, investigational, or unproven.; Magnetic stimulation for stress UI is considered experimental, investigational, or unproven.; Moxibustion for post-stroke UI and stress UI is considered experimental, investigational, or unproven.; Neocontrol System (extracorporeal magnetic innervation) is considered experimental, investigational, or unproven.; Platelet-rich plasma is considered experimental, investigational, or unproven.; Protect PNS System (wireless neuromodulation) for overactive bladder is considered experimental, investigational, or unproven.; Pudendal nerve stimulation is considered experimental, investigational, or unproven.; Radiofrequency micro-remodeling with the SURx System is considered experimental, investigational, or unproven.; Subcutaneous and subfascial tibial nerve stimulation (INTIBIA) is considered experimental, investigational, or unproven.; Subcutaneous tibial nerve stimulation (e.g., eCoin, Altaviva) is considered experimental, investigational, or unproven.; Subfascial tibial nerve stimulation (e.g., BlueWind Revi) is considered experimental, investigational, or unproven.; Stem cell therapy (mesenchymal stem/stromal cells) is considered experimental, investigational, or unproven.; Transcutaneous electrical nerve stimulation (TENS) for overactive bladder is considered experimental, investigational, or unproven.; Transcutaneous tibial nerve stimulation (e.g., Vivally, ZIDA) is considered experimental, investigational, or unproven.; Transperineal implantation of a permanent adjustable balloon continence device (e.g., ACT, ProACT) is considered experimental, investigational, or unproven.; Vibratory perineal stimulation is considered experimental, investigational, or unproven.; Pelvic muscle trainer devices (e.g., Athena, Gyneflex, Kegelmaster) are considered experimental, investigational, or unproven. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Medicare Underpayment Audit

Aetna Urinary Incontinence coverage criteria

What this means for the claim

When does Aetna cover Urinary Incontinence (CPT 51726), and what gets it denied?

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