Non-Implantable Pelvic Floor Electrical Stimulation (PFES) - National Coverage Determination

Original Effective Date: 04/01/2001
Revision Effective Date: 11/01/2013

Effective for dates of service on or after April 1, 2001, the Coverage Issues Manual (CIM) is being revised to permit coverage for non-implantable pelvic floor electrical stimulators. Reference to non-implantable pelvic floor electrical stimulators has been moved from CIM §65-9 (incontinence control devices) to CIM §60-24 (Non-Implantable Pelvic Floor Electrical Stimulator).

Section 60-24, Non-Implantable Pelvic Floor Electrical Stimulator, permits coverage for non-implantable pelvic floor electrical stimulators for the treatment of stress and/or urge urinary incontinence in cognitively intact patients who have failed a documented trial of pelvic muscle exercise (PME) training. A failed trial of PME training is defined as no clinically significant improvement in urinary continence after completing four weeks of an ordered plan of pelvic muscle exercises designed to increase periurethral muscle strength.

Suppliers submitting claims to the DMERC for PFES should use HCPCS code E0740 (Incontinence treatment system, pelvic floor stimulator, monitor, sensor and/or trainer). This code is in the Inexpensive or Routinely Purchased (IRP) reimbursement category. Suppliers are reminded that there must be documentation in the patient's medical record that the coverage criteria outlined in the national policy have been met. This documentation does not have to be routinely sent with the claim but must be available to the DMERC upon request.

Last Updated May 10 , 2017