Close Window
Aetna Aetna
Clinical Policy Bulletin:
Levator Syndrome Treatments
Number: 0679


Policy

Aetna considers high-voltage pulsed electrogalvanic stimulation medically necessary for members with refractory levator syndrome (also known as proctalgia fugax, chronic anal pain syndrome) when all the following criteria are met:

  • A neurological cause for the pain can not be detected; and
  • Member has failed prior conservative treatments, namely, high-fiber diet, withdrawal of drugs that cause constipation (e.g., calcium channel blockers, narcotics) or diarrhea (e.g., antibiotics, quinidine, theophylline), perineal strengthening exercises, rectal massage, warm baths, and drug therapy (e.g., muscle relaxants, non-narcotic analgesics, and sedatives); and
  • No underlying disease has been revealed by anorectal examination or by manometry, radiology, or endoscopy.

Aetna considers high-voltage pulsed electrogalvanic stimulation for levator syndrome experimental and investigational when criteria are not met.

Aetna considers biofeedback medically necessary for members with refractory levator syndrome when criteria listed above are met.  (See CPB 0132 - Biofeedback).

Aetna considers botulinum toxin injections experimental and investigational for the treatment of levator syndrome because their effectiveness for this indication has not been established.  (See CPB 0113 - Botulinum Toxin).

Note: More than 3 60-min sessions, administered over a 10-day period, are not considered medically necessary.  Electrogalvanic stimulators for home use are considered experimental and investigational because they have not been proven to be safe and effective for home use.



Background

Levator syndrome (LS), also known as proctalgia fugax and chronic anal pain syndrome, is a benign disorder characterized by brief, episodic attacks of rectal discomfort and pain of varying severity.  Although the term levator syndrome suggests that spasm of the levator ani muscles is the cause of symptoms, it is still unclear that this mechanism is responsible for all cases of functional rectal discomfort/pain.  Attacks often occur suddenly at night, waking patients from sleep.  In some cases, attacks may occur when the patient is straining at stool or after a bowel movement.  The pain usually lasts for seconds to minutes, and then disappears completely.  Most patients have less than 6 episodes a year, however, some patients experience attacks very frequently.  The condition generally does not appear until after puberty and the frequency and severity of attacks decrease after age 60.  The site of pain is located in the upper anal canal, just above the anal sphincter.  Precipitating factors for this disorder include anxiety, stress, heat, cold, or fatigue (Thompson and Heaton, 1980).

Treatments of patients with LS include high-fiber diet, withdrawal of drugs which have gut effects (e.g., drugs that provoke or worsen constipation including narcotics and calcium channel blockers; drugs that provoke or worsen diarrhea including quinidine, theophylline, and antibiotics), warm baths, rectal massage, perineal strengthening exercises, anti-cholinergic agents, non-narcotic analgesics, sedatives or muscle relaxants.  High-voltage pulsed galvanic stimulation (HVPGS) has also been used in the treatment of this condition, and is not associated with any adverse side effects.  It should be noted that HVPGS is generally not employed to treat patients while they are experiencing symptoms since the attacks usually last only for seconds to minutes.  Instead, this technology is often used as a prophylactic means to reduce the incidence of attacks.  The patient is usually placed in the left lateral decubitus position and a sterile probe is inserted into the anus.  The negative electrode is used and the stimulator is set with a pulse frequency of 80 to 120 cycles per second.  The voltage (intensity) is started at 0, progressively raised to a threshold of patient discomfort, and then is decreased to a level that the patient finds comfortable.  As the patient's tolerance increases, the voltage can be gradually increased to 250 to 350 Volts.  Each treatment session usually lasts between 15 to 60 mins (Oliver et al, 1985; Morris and Newton, 1987).  Several studies have reported short-term success rates that ranged from 65 to 91 % (Sohn et al, 1982; Nicosia and Abcarian, 1985; Oliver et al, 1985; Morris and Newton, 1987; Billingham et al, 1987).

Sohn et al (1982) reported that HVPGS is effective in treating patients with LS.  Eighty patients participated in the study.  Treatment duration was 1 hour per day, 3 times over a period of 3 to 10 days.  Of the 72 patients evaluated, 90 % had excellent (total relief of pain and no recurrence of levator spasm during the course of follow up) or good (with complete resolution of pain but with recurrence of levator spasm at a markedly reduced frequency during the course of follow-up) results.  Nicosia and Abcarian (1985) treated 45 patients with LS using HVPGS.  Treatment time was 15 to 30 mins administered every other day for an average of 5 treatments.  Excellent (complete pain relief) or good (relief was followed by recurrence of pain that responded completely to additional treatment) results were observed in 91 % of patients.

Oliver et al (1985) also employed HVPGS to treat 102 patients with LS.  Patients had tried and failed conservative treatments before being included in this study.  All treatments were 60 mins in duration, and a total of 3 treatments were provided within a 10-day period.  Follow-ups consisted of 1 post-treatment office visit to the attending surgeon or by telephone interviews if the patient failed to return for follow-up examination.  Of the 90 patients with correct diagnoses, 77 % were relieved or improved after treatment.  Morris and Newton (1987) reported their findings of 28 patients with LS treated with HVPGS.  The number of treatments ranged from 3 to 10 with each session lasting for 60 mins.  Overall, 75 % patients reported complete or partial relief of pain/symptoms following HVPGS treatment.

In the study by Billingham et al (1987) 20 patients received an average of 5.6 treatment sessions of HVPGS treatment. Immediately after the first course of treatment, 65 % of patients achieved excellent or good results.  Several months after completion of therapy, results were classified as excellent in 4 (20 %) patients, good in 4 (20 %), fair in 6 (30 %), and poor in 6 (30 %).  The authors concluded that although the long-term results of HVPGS are not as successful as the short-term results, this modality is still a valuable adjunct in the management of patients with LS.

In a randomized, placebo-controlled, cross-over study, Rao et al (2009) examined the safety and effectiveness of botulinum toxin in patients with LS.  A total of 12 patients with LS (greater than or equal to 1 year) received anal intra-sphincteric injections of 100 units of botulinum toxin A and placebo at 90-day intervals using electromyographical guidance.  Daily frequency, severity, duration and intensity of pain (VAS) were recorded.  Anorectal manometry, balloon expulsion and pudendal nerve latency tests were performed to examine the physiological changes and adverse effects.  Seven patients (male/female = 4/3) completed the study and 3 had incomplete data, but all 10 underwent in an intention-to-treat analysis; 2 others dropped out.  After administration of botulinum toxin, the mean frequency, intensity and duration of pain were unchanged (p = 0.31) compared with baseline.  The 90-day mean VAS pain score was 6.79 +/- 0.27 versus baseline score of 7.08 +/- 0.29 (p = 0.25).  Anal sphincter pressures, rectal sensory thresholds, pudendal nerve latency and balloon expulsion times were unchanged after drug or placebo administration.  The authors concluded that injection of botulinum toxin into anal sphincter is safe, but it does not improve anorectal pain in LS.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
90901
90911
97014
97032
Other CPT codes related to the CPB:
46600
64550
90911
HCPCS codes covered if selection criteria are met:
E0746 Electromyography (EMG), biofeedback device
HCPCS codes not covered for indications listed in the CPB:
J0585 Botulinum toxin type A, per unit
J0586 Injection, Abobotulinumtoxina, 5 units
J0587 Botulinum toxin type B, per 100 units
Other HCPCS codes related to the CPB:
E0745 Neuromuscular stimulator, electronic shock unit
E0761 Non-thermal pulsed high frequency radiowaves, high peak power electromagnetic energy treatment device
G0283 Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care
L8680 Implantable neurostimulator electrode, each
L8681 Patient programmer (external) for use with implantable programmable implantable neurostimulator pulse generator
L8682 Implantable neurostimulator radiofrequency receiver
L8683 Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver
L8685 Implantable neurostimulator pulse generator, single array, rechargeable, includes extension
L8686 Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension
L8687 Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension
L8688 Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension
L8689 External recharging system for battery (internal) for use with implantable neurostimulator
ICD-9 codes covered if selection criteria are met:
569.42 Anal or rectal pain


The above policy is based on the following references:
  1. Thompson WG, Heaton KW. Proctalgia fugax. J R Coll Phys Lond. 1980;14(4):247-248. 
  2. Sohn N, Weinstein MA, Robbins RD. The levator syndrome and its treatment with high-voltage electrogalvanic stimulation. Am J Surg. 1982;144(5):580-582. 
  3. Oliver GC, Rubin RJ, Salvati EP, Eisenstat TE. Electrogalvanic stimulation in the treatment of levator syndrome. Dis Colon Rectum. 1985;28(9):662-663. 
  4. Nicosia JF, Abcarian H. Levator syndrome: A treatment that works. Dis Colon Rectum. 1985;28(6):406-408. 
  5. Morris L, Newton RA. Use of high voltage pulsed galvanic stimulation for patients with levator ani syndrome. Phys Ther. 1987;67(10):1522-1525. 
  6. Billingham RP, Isler JT, Friend WG, Hostetler J. Treatment of levator syndrome using high-voltage electrogalvanic stimulation. Dis Colon Rectum. 1987;30(8):584-587.
  7. Potter MA, Bartolo DC. Proctalgia fugax. Eur J Gastroenterol Hepatol. 2001;13(11):1289-1290.
  8. Beers MH, Berkow R, eds. Anorectal disorders: Levator syndrome. In: The Merck Manual of Diagnosis and Therapy. 17th ed. Sec. 3, Ch. 35. White House Station, NJ: Merck & Co.; 2002.
  9. Park DH, Yoon SG, Kim KU, et al. Comparison study between electrogalvanic stimulation and local injection therapy in levator ani syndrome. Int J Colorectal Dis. 2005;20(3):272-276.
  10. Bharucha AE, Wald A, Enck P, Rao S. Functional anorectal disorders. Gastroenterology. 2006;130(5):1510-1518.
  11. Ng CL. Levator ani syndrome - a case study and literature review. Aust Fam Physician. 2007;36(6):449-452.
  12. Falletto E, Masin A, Lolli P, et al; GINS (Italian Group for Sacral Neuromodulation). Is sacral nerve stimulation an effective treatment for chronic idiopathic anal pain? Dis Colon Rectum. 2009;52(3):456-462.
  13. Rao SS, Paulson J, Mata M, Zimmerman B. Clinical trial: Effects of botulinum toxin on Levator ani syndrome -- a double-blind, placebo-controlled study. Aliment Pharmacol Ther. 2009;29(9):985-991.
  14. Chiarioni G, Nardo A, Vantini I, et al. Biofeedback is superior to electrogalvanic stimulation and massage for treatment of levator ani syndrome. Gastroenterology. 2010;138(4):1321-1329.
  15. Chiarioni G. Treatment of levator ani syndrome: Update and future developments. Recenti Prog Med. 2011;102(5):196-201.
  16. Atkin GK, Suliman A, Vaizey CJ. Patient characteristics and treatment outcome in functional anorectal pain. Dis Colon Rectum. 2011;54(7):870-875.
  17. El-Khawand D, Wehbe S, Whitmore K. Botulinum toxin for conditions of the female pelvis. Int Urogynecol J. 2013;24(7):1073-1081.


email this page   


Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
Aetna
Back to top