Intravesical Transurethral Electrical Bladder Stimulation (ITEBS)
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
Intravesical Transurethral Electrical Bladder Stimulation (ITEBS) is a diagnostic and rehabilitative technique for patients with a neurogenic bladder. It consists of multiple sessions of catheterization and electrotherapy to enable the patient to achieve conscious urinary control. The goal is to increase the patient's awareness of bladder fullness to permit timely clean intermittent catheterization.
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
This procedure is considered investigational.
There is no National Coverage Determination (NCD) for Intravesical Transurethral Electrical Bladder Stimulation. In the absence of an NCD, coverage decisions are left to the discretion of Local Medicare Carriers. Novitas Solutions, Inc, the Local Medicare Carrier for jurisdiction JL, has not issued a determination for this service. Therefore, Medicare Advantage Products will follow the Horizon BCBSNJ Medical Policy.
Note: Biofeedback rendered by a practitioner in an office or other facility setting is covered for the treatment of stress and/or urge incontinence in cognitively intact patients who have failed a documented trial of pelvic muscle exercise (PME) training. Biofeedback is not a treatment, per se, but a tool to help patients learn how to perform PME. Biofeedback-assisted PME incorporates the use of an electronic or mechanical device to relay visual and/or auditory evidence of pelvic floor muscle tone, in order to improve awareness of pelvic floor musculature and to assist patients in the performance of PME.
A failed trial of PME training is defined as no clinically significant improvement in urinary incontinence after completing 4 weeks of an ordered plan of pelvic muscle exercises to increase periurethral muscle strength.
For additional information, refer to National Coverage Determination (NCD) for Biofeedback Therapy for the Treatment of Urinary Incontinence (30.1.1). Available to be accessed at CMS National Coverage Determinations (NCDs) Alphabetical Index search page: https://www.cms.gov/medicare-coverage-database/indexes/ncd-alphabetical-index.aspx.
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
Intravesical Transurethral Electrical Bladder Stimulation (ITEBS)
Bladder Stimulation, Electrical
Electrical Stimulation of Bladder
Stimulation of Bladder, Electrical
1. Cheng EY, Richards I, Kaplan WE. Use of bladder stimulation in high risk patients. J Urol. 1996 Aug;156(2 Pt 2):749-752.
2. Decter RM, Snyder P, Laudermilch C. Transurethral electrical bladder stimulation: a follow up report. J Urol. August 1994;152(2):812-4.
3. Decter RM, Snyder P, Rosvanis TK. Transurethral electrical bladder stimulation: initial results. J Urol. August 1992;148(2):651-3.
4. Boone TB, Roehrborn CG, Hurt G. Transurethral intravesical electrotherapy for neurogenic bladder dysfunction in children with myelodysplasia: a prospective, randomized clinical trial. J Urol. August 1992;148(2):550-4.
5. Cheng EY, Richards I, Balcom A, et al. Bladder stimulation therapy improves bladder compliance: results from a multi-institutional trial. J Urol 1996 Aug;156(2 Pt 2):761-764.
6. Kaplan WE. Intravesical electrical stimulation of the bladder: pro. Urology 2000 Jul;56(1):2-4.
7. Decter RM. Intravesical electrical stimulation of the bladder: con. Urology 2000 Jul;56(1):5-8.
8. Aslan AR, Kogan BA. Conservative management in neurogenic bladder dysfunction. Curr Opin Urol. 2002 Nov;12(6):473-7.
9. Gladh G, Mattson S, Lindstrom S. Intravesical electrical stimulation in the treatment of micturition dysfunction in children. Neurourol Urodyn. 2003;22(3):233-42.
10. van Balken MR, Vergunst H, Bemelmans BL. The use of electrical devices for the treatment of bladder dysfunction: a review of methods. J Urol 2004 Sep;172(3):846-51.
11. Lombardi G, Musco S, Celso M, et al. Intravesical electrostimulation versus sacral neuromodulation for incomplete spinal cord patients suffering from neurogenic non-obstructive urinary retention. Spinal Cord 2013 July 51(7):571-8.
12. Lombardi G, Celso M, Mencarini M, et al. Clinical efficacy of intravesical electrostimulation on incomplete spinal cord patients suffering from chronic neurogenic non-obstructive retention: a 15-year single centre retrospective study. Spinal Cord 2013 Mar; 51(3):232-7.
13. Calabro RS, Marullo M, Gervasi G, et al. Does intravesical electrostimulation improve neurogenic constipation? A case report. Eur J Gastroenterol Hepatol 2011 Jul; 23(7):614-6.
14. Hong CH, Lee HY, Jin MH, et al. The effect of intravesical electrical stimulation on bladder function and synaptic neurotransmission in the rat spinal cord after spinal cord injury. BJU Int 2009 Apr; 103(8):1136-41.
15. UpToDate. Treatment of urinary incontinence in women. Literature review current through March 2016.
16. Rawashdeh YF, Austin P, Siggaard C, et al. International Children's Continence Society's recommendations for therapeutic intervention in congenital neuropathic bladder and bowel dysfunction in children. Neurourol Urodyn 2012 Jun: 31(5):615-20.
17. Choi EK, Hong CH, Kim MJ, et al. Effects of intravesical electrical stimulation therapy on urodynamic patterns for children with spinal bifida: 10-year experience. J Pediatr Urol 2013 Dec; 9(6 Pt A):798-803.
18. Lukacz ES, Treatment of Urinary Incontinence in Women. In: UpToDate, Brubaker L, Schmader KE, Melin JA (Eds). UpToDate, Waltham MA. (Accessed March 01, 2018.)
19. Deng H, Liao L, Wu J, et al. Clinical efficacy of intravesical electrical stimulation on detrusor underactivity: 8 Years of experience from a single center. Lucarelli. G, ed. Medicine. 2017;96(38):e8020.
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
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