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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.43 Neurostimulators : 9.2.43.10 Pelvic Floor Stimulation

9.2.43.10
Purchase of a non-implantable pelvic floor stimulator (procedure code E0740) is a benefit of Texas Medicaid for the treatment of stress or urge incontinence in clients who have failed conservative treatment, such as Kegel exercises, behavior management, bladder training, or medication.
Purchase of the pelvic floor stimulator device is limited to once per five years. All accessories and supplies are considered part of the purchase price and are not reimbursed separately.
9.2.43.10.1
Prior authorization is required for the purchase of a pelvic floor stimulator device.
Documentation submitted with the prior authorization request must demonstrate that the client:

Texas Medicaid & Healthcare Partnership
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