Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Magnetic Pelvic Floor Stimulation (MPFS)
Policy #:MA07.014

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

Magnetic pelvic floor stimulation (MPFS) is considered experimental/investigational and, therefore, not covered because current medical literature does not support the clinical efficacy of this procedure in the Medicare population.
Policy Guidelines

This policy is consistent with Medicare's coverage determination.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, magnetic pelvic floor stimulation (MPFS) is not eligible for payment under the medical benefits of the Company’s Medicare Advantage plans because the service is considered experimental/investigational and, therefore, not covered.

Description

Magnetic pelvic floor stimulation (MPFS) is a noninvasive procedure that is used for the treatment of female urinary incontinence. This treatment involves the use of a changing magnetic field to induce electrical depolarization of nerves and muscles of the pelvic floor. A special chair provides the pelvic floor therapy. This chair contains a device that generates a magnetic field that induces contraction of the pelvic floor, levator ani complex, vaginal vault, and the internal and external sphincter muscles. The magnetic field is applied in a "pulsed" fashion resulting in intermittent contraction followed by relaxation of the pelvic muscles to build strength, endurance, and continence over the course of therapy.
References

Novitas Solutions Inc. LCD L35094 Services that are not reasonable and necessary. [CMS.gov website]. Original: 10/01/2015. Revised: 07/01/2017. Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35094&ver=136&Date=&DocID=L35094&bc=iAAAABAAAAAAAA%3d%3d&
Accessed April 9, 2018.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

THE FOLLOWING CODE IS USED TO REPRESENT MAGNETIC PELVIC FLOOR STIMULATION (MPFS):


53899



Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements






Policy History

Revisions from MA07.014:
07/01/2020This policy has been reissued in accordance with the Company's annual review process.
09/25/2019This policy has been reissued in accordance with the Company's annual review process.
05/23/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on Magnetic Pelvic Floor Stimulation (MPFS).
09/27/2017The policy has been reviewed and reissued to communicate the Company’s continuing position on Magnetic Pelvic Floor Stimulation (MPFS).
04/27/2016This policy has been reviewed and reissued to communicate the Company’s continuing position on Magnetic Pelvic Floor Stimulation (MPFS).
01/21/2015This policy has been reviewed and reissued to communicate the Company’s continuing position on Magnetic Pelvic Floor Stimulation (MPFS).
01/01/2015This is a new policy.






Version Effective Date: 01/01/2015
Version Issued Date: 01/01/2015
Version Reissued Date: 07/06/2020