Clinical Policy Title: Pelvic floor stimulation for incontinence

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1 Clinical Policy Title: Pelvic floor stimulation for incontinence Clinical Policy Number: Effective Date: July 1, 2016 Initial Review Date: April 27, 2016 Most Recent Review Date: April 10, 2018 Next Review Date: April 2019 Related policies: Policy contains: Urinary incontinence. Fecal incontinence. Extracorporeal magnetic innervation. Non-implantable pelvic floor electrical stimulation. CP# CP# CP# Surgical and invasive treatments for overactive bladder syndrome. Cecostomy for fecal incontinence. Injectable bulking agents fecal incontinence. ABOUT THIS POLICY: Prestige Health Choice has developed clinical policies to assist with making coverage determinations. Prestige Health Choice s clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of medically necessary, and the specific facts of the particular situation are considered by Prestige Health Choice when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. Prestige Health Choice s clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. Prestige Health Choice s clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, Prestige Health Choice will update its clinical policies as necessary. Prestige Health Choice s clinical policies are not guarantees of payment. Coverage policy Prestige Health Choice considers the use of pelvic floor stimulation using non-implanted electrical devices for the treatment of urinary or fecal incontinence to be investigational/experimental and therefore, not medically necessary. Prestige Health Choice considers the use of pelvic floor stimulation using extracorporeal magnetic innervation for the treatment of urinary incontinence to be investigational/experimental and therefore, not medically necessary. For Medicare members only: Prestige Health Choice considers the use of pelvic floor stimulation using non-implanted electrical 1

2 devices to be clinically proven and, therefore, medically necessary for the treatment of stress and/or urge urinary incontinence in cognitively intact patients who have failed a documented trial of pelvic muscle exercise 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 to increase periurethral muscle strength (CMS, 2006). Limitations: Coverage determinations are subject to benefit limitations and exclusions as delineated by the state Medicaid authority. The Florida Medicaid website may be accessed at All other uses of pelvic floor stimulation using non-implanted electrical devices and extracorporeal magnetic innervation are not medically necessary. Alternative covered services: Behavioral training. Biofeedback. Bladder neck support prosthesis (pessary). Bladder training. Diet modification. Pelvic floor muscle training. Pharmacotherapy (e.g., oxybutynin, tolterodine, darifenacin, solifenacin, fesoterodine, and trospium). Weight loss and exercise. Background Incontinence is a significant health problem in the United States and worldwide. Estimates of prevalence of urinary incontinence vary widely due to inconsistencies in the definitions and differences in populations studied, but urinary incontinence has a significant impact on the quality of life. Urinary incontinence is more common in women than men, and older women experience it more often than younger women. Stress urinary incontinence is the predominant type of urinary incontinence in women and urge urinary incontinence is the predominant type in men, with the exception of urinary incontinence related to radical prostatectomy, in which stress urinary incontinence predominates (Wu, 2014; Markland, 2011). Urinary incontinence in men and women is caused by bladder dysfunction, sphincter dysfunction, or both. Clinical presentation varies depending on the underlying mechanism causing or contributing to urinary incontinence. 2

3 Fecal incontinence affects one in eight community adults with equal distribution among genders. The factors most commonly reported to be associated with FI include increasing age, diarrhea, chronic illness, and urinary incontinence (Ng, 2015; Bharucha, 2015). Treatment depends on the type of incontinence. For urinary incontinence, treatment options include pelvic floor muscle training; physical therapies (e.g., vaginal cones); behavioral therapies (e.g., bladder training); mechanical devices (e.g., continence pessaries); drug therapies (e.g., anticholinergics and duloxetine) and surgical interventions, such as sling procedures and colposuspension (Imamura, 2013). For fecal incontinence, nonsurgical treatment options include biofeedback, lifestyle and dietary modifications, bowel habit interventions, pelvic floor muscle training, rectal irrigation, and drug therapy. When noninvasive options fail, minimally invasive and surgical therapies may be considered (Bharucha, 2015). Pelvic floor stimulation using non-implanted electrical or magnetic devices has been proposed as a nonsurgical option for the treatment of urinary and fecal incontinence. While the precise mechanism of action of pelvic floor electrical stimulation in humans is unclear, the therapeutic intent is to stimulate the pudendal nerve to activate the pelvic floor musculature, which may lead to improved urethral closure. In addition, it may improve partially denervated urethral and pelvic floor muscles through the process of re-innervation. Pelvic floor electrical stimulation refers to the use of non-implanted electrodes, either adhesive pads placed on the skin near the vagina and anus, or a tampon-shaped device placed intra-vaginally or intraanally, to deliver variable rates of electrical current to the pelvic floor musculature. Depending on the etiology of incontinence, pelvic floor electrical stimulation applies variations in electrical pulse amplitude and frequency to mimic and stimulate different physiologic mechanisms of the voiding response. Methods of pelvic floor electrical stimulation vary in location (e.g., vaginal or rectal), stimulus frequency, intensity or amplitude, pulse duration, pulse-to-rest ratio, treatments per day, number of treatment days per week, length of time for each treatment session, and overall time period for device use between clinical and home settings. Initial training occurs in an outpatient or office setting, followed by home treatment with a rented or purchased pelvic floor stimulator. As of January 16, 2016, the U.S. Food and Drug Administration (FDA) has given marketing clearance to 65 pelvic floor electrical stimulation devices (Class II, product code KPI) for the treatment of urinary and fecal incontinence (Hayes, 2016). Extracorporeal magnetic innervation delivers nerve impulses to the pelvic floor area to increase muscular contractions in an attempt to improve bladder control. The FDA has approved one device, the NeoControl Pelvic Floor Therapy System for the treatment of urinary incontinence in women (Neotonus, North Attleboro, MA; Class II, product code KPI). The system consists of a control unit and treatment chair. The chair's therapeutic head generates pulsed magnetic fields that stimulate the perineal tissues, nerves, and muscles, reportedly increasing contractions and improving circulation. The treatment is typically performed twice a week, with each session lasting approximately 20 minutes. A 3

4 complete course of treatment may take eight weeks or more depending on the condition of the pelvic floor muscles when therapy is started. Searches Prestige Health Choice searched PubMed and the databases of: UK National Health Services Centre for Reviews and Dissemination. Agency for Healthcare Research and Quality s National Guideline Clearinghouse and other evidence-based practice centers. The Centers for Medicare & Medicaid Services (CMS). We conducted searches on February 14, Search terms were: "urinary incontinence/therapy", "fecal incontinence/therapeutic use", "fecal incontinence/therapy", "electric stimulation therapy" and "pelvic floor." We included: Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and greater precision of effect estimation than in smaller primary studies. Systematic reviews use predetermined transparent methods to minimize bias, effectively treating the review as a scientific endeavor, and are thus rated highest in evidence-grading hierarchies. Guidelines based on systematic reviews. Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple cost studies), reporting both costs and outcomes sometimes referred to as efficiency studies which also rank near the top of evidence hierarchies. Findings The National Institute for Health and Care Excellence recommends against the routine use of electrical stimulation of women with overactive bladder syndrome, alone or in combination with pelvic floor muscle training. The group does recommend that pelvic floor electrical stimulation be considered in women who cannot actively contract pelvic floor muscles in order to aid motivation and adherence to therapy (NICE, 2013). The European Association of Urology recommended pelvic floor electrical stimulation as an adjunct to behavioral therapy in patients with urgency urinary incontinence. The Association does not recommend pelvic floor electrical stimulation as monotherapy for stress urinary incontinence, or extracorporeal magnetic innervation for the treatment of urinary incontinence or overactive bladder in adult women (EAU, 2015). The American Society of Colon and Rectal Surgeons recommended dietary management, medical management and biofeedback as first-line nonsurgical treatments for patients with fecal incontinence 4

5 and some preserved voluntary sphincter contraction, but made no mention of pelvic floor electrical stimulation in the guideline (Paquette, 2015). The American College of Physicians guideline on the nonsurgical management of urinary incontinence in women did not mention either pelvic floor electrical stimulation or extracorporeal magnetic innervation in its 2014 recommendations of nonsurgical management of urinary incontinence in women (Qaseem, 2014). The most recent systematic (Cochrane) review for non-implanted pelvic floor electrical stimulation for stress urinary incontinence included 56 trials, 18 of which did not report a primary outcome of cure or improvement. The review found that pelvic floor electrical stimulation is probably more effective than placebo, but could not determine if electrical stimulation is as effective as pelvic floor muscle training or other active treatments. The low or very low quality of evidence limits any confidence in results (Stewart, 2017). This systematic review was published a year after another such review by the same Cochrane research team. The earlier review included 63 trials, 44 of which lacked a primary outcome of cure or improvement. Some evidence documented pelvic floor electrical stimulation was more effective than pelvic floor muscle training, but whether it was more effective than placebo was unclear. Low quality of evidence made it difficult to present results with confidence (Stewart, 2016). A Hayes review assessed 15 randomized controlled trials, including 11 of women with stress urinary incontinence and three of men following a prostatectomy. The study concluded that a moderate-sized body of low-quality evidence exists showing benefits to some women with stress urinary incontinence, and a limited amount of low-quality evidence shows improved outcomes in men after radical prostatectomy (Hayes, 2016). Other systematic reviews include: Thirteen studies assessed efficacy of biofeedback and/or pelvic floor electrical stimulation for adult fecal incontinence (young mothers and elderly men and women needing secondline treatment). It concluded that these therapies combined were consistently superior to either as monotherapy, using moderate-to-high quality evidence (Vonthein, 2013). In an Agency for Healthcare Research and Quality review of 63 studies, adding electrostimulation to pelvic floor muscle training did not improve effectiveness (severity and quality of life) among patients with fecal incontinence in 2-3 months (Forte, 2016). Nine trials found pelvic floor electrical stimulation increased continence rates more than did placebo, but only one in nine treated women achieved continence (Shamilyan, 2012). Fifty-five trials (n = 6,608 women with stress urinary incontinence) evaluated efficacy of five interventions; pelvic floor electrical stimulation was less effective than biofeedback and pelvic floor muscle training, and no more effective than placebo (Imamura, 2010). Thirty-seven studies (n = 1058 women with stress urinary incontinence) documented 5

6 electrical stimulation improved quality of life more than placebo, but results of individual studies were inconsistent (Moroni, 2016). Six randomized controlled trials (n=544 men) in a Cochrane study found electrical stimulation reduced incontinence significantly greater than placebo six months after treatment started, but not after 12 months. Adding electrical stimulation to pelvic floor muscle training did not significantly change reduction in urinary incontinence, i.e., 63 versus 61 percent, and showed a significantly greater rate of adverse events, i.e., 17 versus 2 percent (Berghmans, 2013). A total of 30 randomized clinical trials reviewed mostly intravaginal electrical stimulation, which effectively treated urge urinary incontinence, but reported contradictory data regarding stress and mixed incontinence (Schreiner, 2013). Four studies of 210 post-prostatectomy males treated for six to 12 months with pelvic floor muscle training with or without pelvic floor electrical stimulation found a non-significant (three percent) difference in risk ratio (Zhu, 2012). Ninety-six randomized controlled trials and three systematic reviews found pelvic floor electrical stimulation did not resolve urinary incontinence in women (Shamilyan, 2008). An randomized controlled trial of 208 men ages with incontinence post-prostatectomy found that mean incontinence episodes per week after eight weeks of treatment decreased from 28 to 13 after behavioral therapy alone, and a similar reduction of 26 to 12 after behavioral therapy plus pelvic floor electrical stimulation; these reductions were better than controls (25 to 21), but adding pelvic floor electrical stimulation to behavioral therapy did not improve outcomes (Goode, 2011). A recent study of 60 women with overactive bladder syndrome found pelvic floor electrical stimulation did not reduce daily micturitions and nocturnia episodes as effectively as percutaneous tibial nerve stimulation (Scaldazza, 2017). The multiple systematic reviews discussed here do not address any long-term effects of pelvic floor electrical stimulation, while limited evidence of effectiveness has prevented any cost-effectiveness studies to date. Few journal articles have been published on efficacy of extracorporeal magnetic innervation. A systematic review of 11 studies (n=1028 men) treated after radical prostatectomy observed that extracorporeal magnetic innervation and electrical stimulation were found to be initially (within 1-2 months) more effective than pelvic floor muscle training within 1 2 months in one trial, but there were no significant differences existed between groups after three months. Subjects assigned to pelvic floor muscle training achieved continence faster than those who were not (MacDonald, 2007). One study that followed 137 women treated for stress and urge urinary incontinence with extracorporeal magnetic innervation found that 47 percent were dry after six months, but with high recurrence after three years (Doganay, 2010). Another study of 30 women with stress urinary 6

7 incontinence treated with extracorporeal magnetic innervation found 77.8 percent were cured or improved after three months, a figure that was unchanged for one year; however, a gradual decrease occurred in the second year (Hoscan, 2008). A Hayes review of 22 studies found a similar pattern of any improvements not lasting past the short term (Hayes, 2015). Policy updates: A total of five peer-reviewed references were added to this policy in February A total of 1 guideline/other and 11 peer-reviewed references were added to this policy in April Summary of clinical evidence: Citation Stewart (2017) Content, Methods, Recommendations Key points: PFES for women with stress urinary incontinence or urgency predominant mixed urinary incontinence Cochrane review of 56 trials (n=3781) of women with stress urinary incontinence or urgency predominant mixed urinary incontinence. Eighteen trials did not report subjective cure, improvement of SUI or incontinencespecific quality of life. Electronic stimulation more effective than no treatment (moderate quality evidence) No difference in cure or improvement for PFES vs. PFMT (RR 0.85) PFMT + ES vs. PFMT alone (RR 1.10) or ES versus vaginal cones (RR 1.09); evidence is low quality. Stewart (2016) PFES for adults with overactive bladder Hayes (2016) Key points: Cochrane review of 63 trials (n = 4,424) of adults treated for overactive bladder with PFES. 44 of 63 trials did not have outcomes of perception of cure or improvement. Moderate-quality evidence indicated PFES was better than pelvic floor muscle training (RR = 1.60), drug treatment (RR = 1.20), and placebo (RR = 2.26) for perception of improvement. Not clear if PFES better than placebo for urgency urinary incontinence. Low-quality evidence (n = 51) that PFES added to pelvic floor muscle training was superior than when PFES was not added. Key points: PFES as treatment of UI Systematic review of 15 RCTs; 11 RCTs evaluated PFES in 895 women with SUI and 308 women with UUI, and three RCTs evaluated PFES in 258 men with SUI following radical retropubic prostatectomy (RRP). Overall quality: low. Heterogeneity in patient populations, specific treatment protocols, and comparators and short follow-up. PFES appears to be safe and well tolerated in the short term. Most common adverse effects were pain or discomfort with the electrical stimulation. For women with SUI or UUI or men with UUI, PFES offers limited benefit at best. 7

8 Citation European Association of Urology (2015) Guidelines on UI Vonthein (2013) PFES and/or biofeedback (BF) for FI Shamliyan (2012) Content, Methods, Recommendations The optimal number of sessions or duration of treatment is unclear. Key points: Evidence synthesis of two health technology assessments and three systematic reviews, comprising 15 trials that used different comparison methods. Overall quality: low. Heterogeneous stimulation parameters, treatment regimens and outcome parameters. Most evidence on PFES refers to women with SUI. No evidence found for electromagnetic stimulation. In adults with UI, conflicting evidence of effectiveness of PFES versus sham stimulation or pharmacotherapy, and whether PFES adds to the benefit of PFMT alone. Key points: Systematic review and meta-analysis of 13 RCTs comparing BF alone or in combination with PFES; PFES alone to other treatments. Two populations represented were 1) young mothers and 2) predominately elderly men and women in need of a second-line conservative treatment and no obvious need for surgery. Overall quality: moderate to high quality. Heterogeneity with respect to spectrum of patients and treatment protocols, poor reporting of technological details and safety outcomes. No trial showed superiority of control, BF alone or PFES alone when compared with BF + PFES. Superiority of BF + PFES over any monotherapy was demonstrated in several trials. High-quality evidence suggests AM-MF PFES plus electromyography BF is the best second-line treatment for FI. Key points: For the Agency for Healthcare Research and Quality Nonsurgical treatments for UI in community-dwelling women Systematic review of nine RCTs of intra-vaginal PFES and five RCTs of ExMI. Overall quality: high for PFES, low to moderate for ExMI. Poor adherence. PFES increased continence rate, improved SUI and improved quality of life compared to sham. For UUI, MUI, or overactive bladder (OAB), comparable outcomes between PFES as monotherapy or combination therapy versus other nonsurgical treatments or pharmacological treatments. ExMI improved UI but did not increase urinary continence more than sham stimulation. Evidence of improved quality of life was low. References Professional society guidelines/other: Lucas MG, Bedretdinova D, Berghmans LC, et al. Guidelines on urinary incontinence. European Association of Urology. March, Incontinence_LR1.pdf. Accessed February 14,

9 National Collaborating Centre for Women s and Children s Health. Urinary incontinence: the management of urinary incontinence in women. London: National Institute for Health and Care Excellence (NICE) Clinical guideline no Accessed February 14, National Institute of Diabetes and Digestive and Kidney Diseases website. Fecal incontinence. Accessed February 14, Paquette IM, Varma MG, Kaiser AM, Steele SR, Rafferty JF. The American Society of Colon and Rectal Surgeons' Clinical Practice Guideline for the Treatment of Fecal Incontinence. Dis Colon Rectum. 2015; 58(7): Qaseem A, Dallas P, Forciea MA, et al. Nonsurgical management of urinary incontinence in women: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2014; 161(6): Shamliyan T WJ, Kane RL. Nonsurgical Treatments for Urinary Incontinence in Adult Women: Diagnosis and Comparative Effectiveness [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ) (US); 2012 Apr. (Comparative Effectiveness Reviews, No. 36.) AHRQ website. Accessed February 14, Peer-reviewed references: Berghmans B, Hendriks E, Bernards A, de Bie R, Omar MI. Electrical stimulation with non-implanted electrodes for urinary incontinence in men. Cochrane Database Syst Rev Jun 6;(6):CD doi: / CD pub5. Bharucha AE, Dunivan G, Goode PS, et al. Epidemiology, pathophysiology, and classification of fecal incontinence: state of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) workshop. Am J Gastroenterol. 2015;110(1): Doganay M, Kilic S, Yilmaz N. Long-term of extracorporeal magnetic innervations in the treatment of women with urinary incontinence: results of 3-year follow-up. Arch Gynecol Obstet. 2010;282(1): Forte ML, Andrade KE, Butler M (eds.), et al. Treatments for Fecal Incontinence [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2016 Mar. Report No.: 15(16)-EHC037-EF. AHRQ Comparative Effectiveness Reviews. Goode PS, Burgio KL, Johnson TM 2 nd, et al. Behavioral therapy with or without biofeedback and pelvic 9

10 floor electrical stimulation for persistent postprostateceomy incontinence: a randomized controlled trial. JAMA. 2011;305(2): Hayes Inc., Hayes Medical Technology Report. Pelvic Floor Electrical Stimulation for the Treatment of Urinary Incontinence. Lansdale, PA. Hayes Inc. February 26, Hayes Inc. Medical Technology Directory. Extracorporeal magnetic stimulation for urinary incontinence. Lansdale PA: Hayes, Inc. February 24, Hoscan MB, Dilmen C, Perk H, et al. Extracorporeal magnetic inervation for the treatment of stress urinary incontinence: results of two-year follow-up. Urol Int. 2008;81(2): Imamura M, Jenkinson D, Wallace S, et al. Conservative treatment options for women with stress urinary incontinence: clinical update. Br J Gen Pract. 2013;63(609): Imamura M, Abrams P, Bain C, et al. Systematic review and economic modelling of the effectiveness and cost-effectiveness of non-surgical treatments for women with stress urinary incontinence. Health Technol Assess. 2010;14(40): Jerez-Roi J, Souza DL, Espelt A, Costa-Marin M, Belda-Molina AM. Pelvic floor electrostimulation in women with urinary incontinence and/or overactive bladder syndrome: a systematic review. Actas Urol Esp. 2013;37(7): MacDonald R, Fink HA, Huckabay C, Monga M, Wilt TJ. Pelvic floor muscle training to improve urinary incontinence after radical prostatectomy: a systematic review of effectiveness. BJU Int. 2007;100(1): Markland AD, Richter HE, Fwu CW, Eggers P, Kusek JW. Prevalence and trends of urinary incontinence in adults in the United States, 2001 to J Urol. 2011;186(2): Moroni RM, Magnani PS, Haddad JM, Castro Rde A, Brito LG. Conservative treatment of stress urinary incontinence: a systematic review with meta-analysis of randomized controlled trials. Rev Bras Ginecol Obstet. 2016;38(2): Ng KS, Sivakumaran Y, Nassar N, Gladman MA. Fecal incontinence: community prevalence and associated factors a systematic review. Dis Colon Rectum. 2015;58(12): Scaldazza CV, Morosetti C, Giampieretti R, Lorenzetti R, Baroni M. Percutaneous tibial nerve stimulation versus electrical stimulation with pelvic floor muscle training for overactive blader syndrome in women: results of randomized controlled study. Int Braz J Urol. 2017;43(1):

11 Schreiner L, Santos TG, Souza AB, Nygaard CC, Silva Filho IG. Electrical stimulation for urinary incontinence in women: a systematic review. Int Braz J Urol. 2013;39(4): Shamilyan TA, Kane RL, Wyman J, Wilt TJ. Systematic review: randomized, controlled trials of nonsurgical treatments for urinary incontinence in women. Ann Intern Med. 2008;18; Stewart F, Gameiro LF, El Dib R, Gameiro MO, Kapoor A, Amaro JL. Electrical stimulation with nonimplanted electrodes for overactive bladder in adults. Cochrane Database Syst Rev. 2016;12:CD Doi: / CD pub4. Stewart F, Berghmans B, Bo K, Glazener CM. Electrical stimulation with non-implanted devices for stress urinary incontinence in women. Cochrane Database Syst Rev Dec 22;12:CD doi: / CD pub2. Vonthein R, Heimerl T, Schwandner T, Ziegler A. Electrical stimulation and biofeedback for the treatment of fecal incontinence: a systematic review. Int J Colorectal Dis. 2013; 28(11): Wu JM, Vaughan CP, Goode PS, et al. Prevalence and trends of symptomatic pelvic floor disorders in U.S. women. Obstet Gynecol. 2014; 123(1): Zhu YP, Yao XD, Zhang SL, Dai B, Ye DW. Pelvic floor electrical stimulation for postprostatectomy urinary incontinence: a meta-analysis. Urology. 2012;79(3): CMS National Coverage Determinations (NCDs): Non-Implantable Pelvic Floor Electrical Stimulator. CMS website. Effective October 19, KeyWord=pelvic+floor+electrical+stimulator&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gA AAACAAAAAAAA%3d%3d&. Accessed February 14, Local Coverage Determinations (LCDs): None. Commonly submitted codes Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and bill accordingly. 11

12 CPT Code Description Comments Extracorporeal magnetic innervation (Unlisted procedure, urinary system) Application of a modality to one or more areas; electrical stimulation unattended Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes, requiring direct patient contact by the provider ICD-10 Code Description Comments N39.3 Stress incontinence (female) (male) N39.41-N Other specified urinary incontinence (code range) R15.0-R15.9 Fecal incontinence (code range) R32 Unspecified urinary incontinence HCPCS Level II Code E0740 Description Incontinence treatment system; pelvic floor stimulator, monitor, sensor and/or trainer Comments 12