Criteria
Urinary Stress Incontinence
The use of United States Food and Drug Administration (U.S. FDA) approved bulking agents for the treatment of urinary stress incontinence may be considered medically necessary in individuals who have failed appropriate conservative therapy for at least three (3) months.
- Note: Conservative therapy for stress urinary incontinence may include:
- Pelvic floor muscle exercises (Kegel exercises); or
- Behavioral changes, such as
- Fluid management; or
- Smoking cessation; or
- Weight loss; or
- Moderation of physical activities that provoke stress urinary incontinence.
- Additional options may include:
- Intravaginal estrogen therapy; or
- Use of a pessary; or
- Treatment of other underlying causes of stress incontinence in individuals amenable to these treatments.
Additional treatments for reoccurrence of stress urinary incontinence with a periurethral bulking agent may be considered medically necessary following successful treatment in the past six (6) to 12 months.
Further treatment of stress urinary incontinence with a bulking agent is considered not medically necessary when there is failure to improve after five (5) separate treatment sessions.
The use of bulking agents to treat stress urinary incontinence not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore, non-covered, because the safety and/or effectiveness of this service cannot be established by the published peer-reviewed literature including but not limited to the following:
- Teflon; and
- Autologous fat; and
- Autologous ear chondrocytes; and
- Autologous cellular therapy, including but not limited to:
- Myeloblasts; and
- Fibroblasts; and
- Muscle derived stem cells; and
- Adipose derived stem cells.
Procedure Codes
