JOHNS HOPKINS HEALTHCARE
Policy Number: CMS05.07
Effective Date: 6/4/09
Review Date: 08/29/12
Medical Policy: Enuresis Alarms in Children
Department: Medical Management
Lines of Business: EHP, PPMCO, USFHP
ACTION:
New Policy
Revising Policy Number
Superseding Policy Number
Archiving Policy Number: CMS05.07
Page 1 of 4
Retiring Policy Number
ACTIVE AND ARCHIVED
This document has been archived as of 8/29/12 and is no longer scheduled for review for either one or more of the following reasons:
1. This document is either primarily administrative in nature and / or
2. It addresses operational issues only and / or
3.
4.
It is mandated by statute or regulation and / or
It is unlikely that further published literature would change the determination.
ARCHIVED POLICIES REMAIN ACTIVE FOR THE PURPOSE OF MEDICAL NECESSITY
DETERMINATION
Johns Hopkins HealthCare provides a full spectrum of health care products and services for
Employer Health Programs, Priority Partners, and US Family Health Plan. Each line of business possesses its own unique contract and guidelines which, for benefit and payment purposes, should be consulted to know what benefits are available, before carrying out any form of treatment or service. Specific contract benefits, guidelines or policies supersede the information outlined in this policy.
POLICY :
For US Family Health Plan (USFHP) TRICARE Policy Manual 6010.54-M, August 1, 2001,
Urinary System: Chapter 4, Section 14.1
I.
When benefits are provided under the member’s contract, JHHC considers enuresis alarms medically necessary when all of the following conditions are met:
A.
Patient is 8 years or older with well documented nocturnal enuresis.
B.
There is no history of a disorder or condition that would interfere with the ability to evaluate the meaning of the alarm.
C.
Enuresis alarms are purchased from JHHC approved vendor or web site.
Review Dates: 6/4/09, 2010, 08/29/11, 8/29/12

JOHNS HOPKINS HEALTHCARE
Policy Number: CMS05.07
Effective Date: 6/4/09
Review Date: 08/29/12
Medical Policy: Enuresis Alarms in Children
Department: Medical Management
Lines of Business: EHP, PPMCO, USFHP
Page 2 of 4
II.
JHHC will cover only one device per user.
BACKGROUND:
Enuresis (bedwetting) is a condition which affects around 15-20% of five year olds, and up to
2% of young adults. It is a medical term for involuntary urination while asleep after the age at which bladder control usually occurs. Nocturnal enuresis, which accounts for 80% of all enuresis cases, is usually divided into primary and secondary forms:
6
A.
Primary Nocturnal Enuresis
Primary (or continuous) enuresis describes a child who has never been dry during the night. Nocturnal enuresis accounts for 75-80% of all enuresis cases.
B.
Secondary Nocturnal Enuresis
Secondary enuresis refers to a child who develops bed-wetting after having been dry for at least 6 months.
Although 97% of children with enuresis have no organic etiology, secondary enuresis, is more likely to have an organic cause for their enuresis.
C.
Prevalence:
1.
Affects 40% of 3 year-olds, 25% of 4 year-olds, 15% of 5 year-olds, 10% 6 year-olds, and 5% of 10 year-olds
2.
The spontaneous remission rate is 15% per year
3.
Slight male predominance (60%)
D.
Enuresis Alarm Therapy:
1.
Conditioning therapy using an Enuresis Alarm is the most effective means of controlling nocturnal enuresis. Enuresis alarm is activated when a sensor placed in the undergarment or on a bed pad, detects moisture.
2.
The arousal device is usually an auditory alarm and/ or a vibrating belt or pager. The alarm should be used continuously until the child has had between
21 and 28 consecutive dry nights. This usually takes between 12 and 16 weeks.
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3.
Enuresis Alarm Therapy is successful in about three quarters of children.
4.
The Food and Drug Administration (FDA) have approved several Enuresis
Alarms medical devices, product classification Class II 510 (k) devices for safety and efficacy.
11
CODING INFORMATION:
CPT Copyright 2013 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
Review Dates: 6/4/09, 2010, 08/29/11, 8/29/12

JOHNS HOPKINS HEALTHCARE
Policy Number: CMS05.07
Effective Date: 6/4/09
Review Date: 08/29/12
Medical Policy: Enuresis Alarms in Children
Department: Medical Management
Lines of Business: EHP, PPMCO, USFHP
Page 3 of 4
Note: The following CPT/HCPCS codes are included below for informational purposes.
Inclusion or exclusion of a CPT/HCPCS code(s) below does not signify or imply member coverage or provider reimbursement. The member's specific benefit plan determines coverage and referral requirements. Please see EHP, Priority Partners, and/or US Family
Health Plan Outpatient Referral Guidelines for Pre-Authorization Requirements. All inpatient admissions require pre-authorization.
Compliance with the provision in this policy may be monitored and addressed through post-payment
data analysis and/or medical review audits
Employer Health
Programs (EHP) **See
Specific Summary Plan
Description (SPD) then apply policy criteria
HCPCS
CODES
S8270
Priority Partners
( PPMCO) refer to
COMAR guidelines and
PPMCO SPD then apply policy criteria
US Family Health Plan (USFHP), TRICARE
Medical Policy supersedes JHHC Medical Policy. If there is no Policy in TRICARE then apply the
Medical Policy Criteria
DESCRIPTION
Enuresis alarm, using auditory buzzer and/or vibration device
REFERENCES:
PRIMARY SCIENTIFIC CLINICAL RESEARCH REFERENCE ARTICLES
1.
Fritz, G., Rockney, R., Bernet, W., et. al. (2004). Practice Parameter for the Assessment and Treatment of Children and Adolescents with Enuresis [Abstract]. Journal American
Academy of Child & Adolescent Psychiatry , 43(12), 1540-1550. Retrieved from: http:// aacap.org/page.ww?section=Summaries&name=Summary+of+The+Practice+Parameter+F or+The+Assessment+And+Treatment+Of+Children+And+Adolescents+With+Enuresis .
2.
Glazener, C.M., Evans, J.H.C., Peto, R.E., (2005, April 18). Alarm Interventions for
Nocturnal Enuresis in Children [Abstract]. Cochrane Database Systematic Review , 18:2,
CD002911. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/15846643 .
3.
Jalkut, M.W., Lerman, S.E., Churchill, B.M., (2001, December). Enuresis [Abstract].
Pediatric Clinics of North America , 48(6), 1461-1488. Retrieved from: http://www. ncbi.nlm.nih.gov/pubmed/11732125?dopt=Abstract .
4.
DryBuddy: A Solution for Primary Nocturnal Enuresis (Bedwetting). Retrieved from: http://www.drybuddy.com/?gclid=COuVy8uhm6MCFQGdnAodTm3KsQ .
5.
Kidzhealth 92009-2011). Bed Wetting/Nocturnal Enuresis. Retrieved from: http://www.kidzhealth.co.nz/information/surgery-info/bed-wetting-nocturnal-enuresis .
Review Dates: 6/4/09, 2010, 08/29/11, 8/29/12

JOHNS HOPKINS HEALTHCARE
Policy Number: CMS05.07
Effective Date: 6/4/09
Review Date: 08/29/12
Medical Policy: Enuresis Alarms in Children
Department: Medical Management
Lines of Business: EHP, PPMCO, USFHP
CLINICAL TECHNOLOGY RESEARCH AND CONSULTING REFERENCES
Page 4 of 4
6.
Naiwen, D., Gonzales Jr, E., (2011, January). Management of Nocturnal Enuresis in
Children [Abstract]. Retrieved from: http://www.uptodate.com/online/content/ topic.do?topicKey=gen_pedi/27768&selectedTitle=1%7E71&source=search_result .
7.
UpToDate (2011). Enuresis Alarms. Retrieved from: http://www.uptodate.com/online/ content/image.do?imageKey=PEDS%2F19569 .
HEALTH PLAN REFERENCES
8.
CIGNA Medical Coverage Policy. (2011, April 15). Nocturnal Enuresis Treatment
Services, Policy Number: 0044. Retrieved from: http://www.cigna.com/customer_care/ healthcare_professional/coverage_positions/medical/mm_0044_coveragepositioncriteria_b edwetting_monitors.pdf
.
9.
Aetna Clinical Policy Bulletin. (2010, April, 23). Nocturnal Enuresis Treatments, Policy
Number: 0431. Retrieved from: http://www.aetna.com/cpb/medical/data/400 _499/
0431.html
.
REGULATORY GOVERNMENT REFERENCES
10.
TRICARE Policy Manual 6010.54-M, August 1, 2001, Urinary System: Chapter 4, Section
14.1, C-93, February 23, 2009, at: http://manuals.tricare.osd.mil/ .
11.
U.S. Food and Drug Administration (FDA), Enuresis Alarm, Medical Device, Class II.
Retrieved from: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPCD/ classification.cfm?ID=1829 .
Approval Signature: Chester W. Schmidt Jr., M.D.
Date: 8/29/2012
Chester W. Schmidt Jr., M.D.
Chief Medical Officer, Johns Hopkins HealthCare LLC
Chairman, Medical Policy Committee
Review Dates: 6/4/09, 2010, 08/29/11, 8/29/12