Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Anorectal Manometry, Electromyography (EMG) of Anorectal or Urethral Sphincters; Biofeedback Training for Perineal Muscles and Anorectal or Urethral Sphincters
Policy #:MA07.018b

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.

MEDICALLY NECESSARY

ANORECTAL MANOMETRY
Anorectal manometry studies of the anal sphincter for conditions of constipation and fecal incontinence are considered medically necessary and, therefore, covered when all of the following criteria are met:
  • It is clinically necessary to rule in or rule out diagnoses of constipation, mechanical, or functional incontinence, or other forms of incontinence.
    • For cases of constipation, prior to the anorectal manometry:
      • Medications that can cause constipation should be discontinued.
      • Constipation secondary to other diseases should be excluded.
      • A trial of fiber and/or other laxatives should have been conducted.
  • There is appropriate evaluation and justification prior to the test (e.g., history and physical).
  • The test is likely to affect the course of therapy (e.g., pelvic floor training, surgical intervention, pharmacologic intervention, biofeedback therapy, or other clinically accepted interventions).

ELECTROMYOGRAPHY (EMG)
EMG studies of the urethral or anal sphincters for conditions of constipation, fecal incontinence, or urinary incontinence are considered medically necessary and, therefore, covered when all of the following criteria are met:
  • It is clinically necessary to rule in or rule out diagnoses of constipation, stress, or urge incontinence, mechanical or functional incontinence, or other forms of incontinence.
    • For cases of constipation, prior to the EMG:
      • Medications that can cause constipation should be discontinued.
      • Constipation secondary to other diseases should be excluded.
      • A trial of fiber and/or other laxatives should have been conducted.
  • There is appropriate evaluation and justification prior to the test (e.g., history and physical).
  • The test is likely to affect the course of therapy (e.g., pelvic floor training, surgical intervention, pharmacologic intervention, biofeedback therapy or other clinically accepted interventions)

PROFESSIONAL AND TECHNICAL REIMBURSEMENT FOR NEEDLE EMG
  • Only physicians (MD/DO) are eligible to receive reimbursement for the professional component of EMG. Physicians may also receive reimbursement for the technical component if they performed that service.
  • Non-physician professional providers are only eligible to receive reimbursement for the technical component of EMG.

STATE OF NEW JERSEY PERFORMANCE OF NEEDLE EMG

In the state of New Jersey, as defined by the scope of practice regulations, only a physician may perform needle EMG studies.

BIOFEEDBACK (URINARY STRESS or URGE INCONTINENCE)
Biofeedback for the treatment of urinary stress or urge incontinence is considered medically necessary and, therefore, covered when all of the following criteria are met;
  • The individual requires biofeedback due to one of the following:
    • Muscle re-education of specific muscle groups
    • Treatment of incapacitating muscle spasm and/or weakness
  • More conventional treatments (i.e., heat, cold, massage, exercise, support) must have been tried and not been successful prior to initiating biofeedback for urinary stress incontinence.
  • The individual has failed a documented trial of pelvic muscle exercise (PME) training designed to increase periurethral muscle strength
    • Failure is defined as no clinically significant improvement in urinary continence after completing four weeks of an ordered regimen of PMEs.
  • The individual is motivated to actively participate in the treatment plan and is responsive to the care plan requirements (e.g., practice and follow-through at home).
  • The individual is capable of participating in the treatment plan (physically and cognitively).
  • The condition can be appropriately treated with biofeedback (ie, there is no pathology to prevent success of the treatment).

BIOFEEDBACK (FECAL INCONTINENCE/CONSTIPATION)
Biofeedback for the treatment of fecal incontinence/constipation is considered medically necessary and, therefore, covered when all of the following criteria are met;
  • The individual requires biofeedback due to one of the following:
    • Muscle re-education of specific muscle groups
    • Treatment of pathological muscle abnormalities such as muscle spasticity, incapacitating muscle spasm, or weakness, where more conventional treatments have not been successful.
  • The individual is motivated to actively participate in the treatment plan and is responsive to the care plan requirements (e.g., practice and follow-through at home).
  • The individual is capable of participating in the treatment plan (physically and cognitively).
  • The condition can be appropriately treated with biofeedback (ie, there is no pathology to prevent success of the treatment).

NOT COVERED

Biofeedback training supplied in the home or in a group setting is not covered by the Company because it is a service not covered by Medicare. Therefore, it is not eligible for reimbursement consideration.

NOT MEDICALLY NECESSARY

When biofeedback is effective for the treatment of urinary and/or fecal incontinence/constipation, it is usually effective within four sessions. Additional sessions are considered not medically necessary and, therefore, not covered unless there is clear documentation of progress and additional benefit from further therapy.

REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must reflect the medical necessity of the care and services provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

An order for each item billed must be signed and dated by the professional provider who is treating the member and kept on file by the supplier. Medical record documentation must include a shipment confirmation or member's receipt of supplies and equipment. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Policy Guidelines

This policy is consistent with Medicare's coverage determination. The Company's reimbursement methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, anorectal manometry, electromyography (EMG) of anorectal or urethral sphincters, biofeedback training for perineal muscles, and anorectal or urethral sphinctersare covered under the medical benefits of the Company's Medicare Advantage products when the medical necessity criteria listed in the medical policy are met. However, services that are identified in this policy as noncovered are not eligible for coverage or reimbursement by the Company.

Description

Anorectal manometry is a diagnostic test that measures anal sphincter pressures and provides an assessment of rectal sensation, rectoanal reflexes, and rectal compliance. Electromyography (EMG) of the anal or urethral sphincter is a diagnostic test that measures muscle activity and is used to assist in evaluating fecal or urinary incontinence, dysfunctional elimination of bowel and bladder, and neurogenic bladder dysfunction leading to functional abnormalities of the muscular sphincter.

Biofeedback training of the pelvic muscles uses an electronic or mechanical device to relay visual and/or auditory evidence of pelvic floor muscle activity in order to improve awareness and control of pelvic floor muscle contractions.

Biofeedback may include measurement of muscle contraction through surface EMG, vaginal or rectal sensors, and/or rectal manometry devices. Such services, when performed for biofeedback monitoring, are part of the biofeedback service.
References

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 30.1.1: Biofeedback therapy for the treatment of urinary incontinence. [CMS Web site]. 07/01/01. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=42&ncdver=1&bc=AgAAQAAAAAAA&. Accessed November 02, 2018.

Novitas Solutions, Inc. Local Coverage Determination (LCD).L35081: Nerve conduction studies and electromyography. [Novitas Solutions, Inc. Web site]. 10/01/15. Revised 10/01/2018. Available at: https://www.cms.gov/medicare-coverage-database/license/cpt-license.aspx?from=~/overview-and-quick-search.aspx&npage=/medicare-coverage-database/details/lcd-details.aspx&LCDId=35081&ContrId=332&ver=66&ContrVer=1&CntrctrSelected=332*1&Cntrctr=332&s=All&DocType=All&bc=AAAAAAQAAAAA&. Accessed November 02, 2018.

Novitas Solutions, Inc. Local Coverage Determination (LCD). L34977: Anorectal Manometry, Anal Electromyography, and Biofeedback Training for Perineal Muscles and Anorectal or Urethral Sphincters. [Novitas Solutions, Inc. Web site]. 10/01/15. Revised 10/01/2016. Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34977&ver=13&name=314*1&UpdatePeriod=804&bc=AAAAEAAAAAAA&. Accessed November 02, 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)

MEDICALLY NECESSARY

51784, 51785, 90901, 90912, 90913, 91117, 91122



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)

MEDICALLY NECESSARY

G83.4 Cauda equina syndrome

K59.00 Constipation, unspecified

K59.01 Slow transit constipation

K59.02 Outlet dysfunction constipation

K59.09 Other constipation

K59.4 Anal spasm

N31.2 Flaccid neuropathic bladder, not elsewhere classified

N31.9 Neuromuscular dysfunction of bladder, unspecified

N36.42 Intrinsic sphincter deficiency (ISD)

N36.43 Combined hypermobility of urethra and intrinsic sphincter deficiency

N36.44 Muscular disorders of urethra

N39.3 Stress incontinence (female) (male)

N39.41 Urge incontinence

N39.42 Incontinence without sensory awareness

N39.43 Post-void dribbling

N39.44 Nocturnal enuresis

N39.45 Continuous leakage

N39.46 Mixed incontinence

R15.0 Incomplete defecation

R15.1 Fecal smearing

R15.2 Fecal urgency

R15.9 Full incontinence of feces

R33.0 Drug induced retention of urine

R33.8 Other retention of urine

R33.9 Retention of urine, unspecified

R35.0 Frequency of micturition

R39.14 Feeling of incomplete bladder emptying

R39.15 Urgency of urination



HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A


Misc Code

N/A:

N/A


Coding and Billing Requirements






Policy History

MA07.018b:
01/01/2020This version of the policy will become effective 01/01/2020. This policy has been identified for the CPT code update, effective 01/01/2020.

The following CPT codes have been added to the policy:

90912; 90913 (Medically Necessary)

The following CPT code has been deleted from this policy:

90911

MA07.018a
11/20/2019This policy has been reissued in accordance with the Company's annual review process.
11/21/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on Anorectal Manometry, Electromyography (EMG) of Anorectal or Urethral Sphincters; Biofeedback Training for Perineal Muscles and Anorectal or Urethral Sphincters
06/07/2017This policy has been reissued in accordance with the Company's annual review process.
02/03/2016The policy has been reviewed and reissued to communicate the Company’s continuing position on anorectal manometry, electromyography (EMG) of anorectal or urethral sphincters; biofeedback training for perineal muscles and anorectal or urethral sphincters.
10/01/2015The following ICD-10 CM codes have been added to this policy:

G83.4, K59.00, K59.01, K59.02, K59.09, K59.4, N31.2, N31.9, N36.42, N36.43, N36.44, N39.3, N39.41 N39.42, N39.43, N39.44, N39.45, N39.46, R15.0, R15.1, R15.2, R15.9, R33.0, R33.8, R33.9, R35.0, R39.14, R39.15


MA07.018
02/18/2015The policy has been reviewed and reissued to communicate the Company’s continuing position on Anorectal Manometry, Electromyography (EMG) of Anorectal or Urethral Sphincters; Biofeedback Training for Perineal Muscles and Anorectal or Urethral Sphincters.
01/01/2015This is a new policy.





Version Effective Date: 01/01/2020
Version Issued Date: 12/31/2019
Version Reissued Date: N/A