Medical Policy
Effective Date:12/07/2011 Title:Transurethral Radiofrequency Treatment, Urinary Stress Incontinence
Revision Date: Document:BI330:00
CPT Code(s):53860
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    This procedure is considered experimental and investigational and is not covered.

2)    Radiofrequency remodeling of the bladder neck and urethra has been proposed as a treatment for urinary stress incontinence. 

3)    This procedure has not been scientifically studied in adequate fashion to determine if this technology offers any benefit in improving health outcomes.
Medical Statement

Radiofrequency remodeling of the female urinary tract to treat stress urinary incontinence is considered investigational and is not covered.

Hayes Rating “C”  (more research needed)

 

Codes Used In This BI:

 

53860

Transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence
Limits
Intentially left empty
Reference

Appell RA, Juma S, et al.(2006) Transurethral radiofrequency energy collagen micro-remodeling for the treatment of female stress urinary incontinence. Neurourol Urodyn, 2006; 25:331-6.

Appell RA, Singh G, Klimberg IW, et al.(2007) Nonsurgical, radiofrequency collagen denaturation for stress urinary incontinence: retrospective 3-year evaluation. Expert Rev Med Devices. 2007 Jul;4(4): 455-461.

Appell, RA.(2008) Transurethral collagen denaturation for women with stress urinary incontinence. Curr Urol Rep. 2008 Sep;9(5):373-379.

Buchsbaum GM, McConville J, et al.(2006) Outcome of transvaginal radiofrequency for treatment of women with stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct, 2006; [Epub ahead of print].

Dmochowski RR, Avon M, et al.(2003) Transvaginal radio frequency treatment of the endopelvic facsia: a prospective evaluation for the treatment of genuine stress urinary incontinence. J Urol, 2003; 169:1028-32.

Elser DM, Mitchell GK, Miklos JR, et al.(2009) Nonsurgical transurethral collagen denaturation for stress urinary incontinence in women: 12-month results from a prospective long-term study. J Minim Invasive Gynecol. 2009 Jan-Feb;16(1):56-62.

Hayes Technology Brief (2018) Transurethral Radiofrequency Micro-Remodeling Using the Renessa® System (Novasys Medical Inc.) for Female Stress Urinary Incontinence

Ismail SI.(2008) Radiofrequency remodelling of the endopelvic fascia is not an effective procedure for urodynamic stress incontinence in women. Int Urogynecol J Pelvic Floor Dysfunct. 2008 Sep;19(9):1205-1209.

Karliner L.(2008) California Technology Assessment Forum. Radiofrequency micro-remodeling for the treatment of female stress urinary incontinence. October 2008. Available at  http://www.ctaf.org/content/general/detail/930 . Last accessed Occtober 26, 2011.

Lenihan JP.(2005) Comparison of the quality of life after nonsurgical radiofrequency energy tissue micro-remodeling in premenopausal and postmenopausal women with moderate-to-severe stress urinary incontinence. Am J Ob Gyn 2005; 192:1995-8.

McDougall EM, Heidorn CA, et al.(1999) Laparoscopic bladder neck suspension fails the test of time. J Urol, 1999; 162:2078-81.

Ross JW, Galen DI, et al.(2002) A prospective multisite study of radiofrequency bipolar energy for treatment of genuine stress incontinence. J Am Assoc Gynecol Laparosc, 2002; 9:493-9.

 
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.