Description

Sacral nerve neuromodulation (SNM), is defined as the implantation of a permanent device that modulates the neural pathways controlling bladder or rectal function.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Criteria

Urinary Incontinence and Non-obstructive Retention

A trial period of SNM (e.g., InterStim Continence Control Therapy System), with either percutaneous nerve stimulation or a temporarily implanted lead may be considered medically necessary when ALL of the following criteria are first met:

• The individual has a diagnosis of ONE of the following:
  • Urinary urge incontinence; or
  • Urgency-frequency syndrome; or
  • Non-obstructive urinary retention; or
  • Overactive bladder; and
• The individual has failed or has an intolerance to AT LEAST TWO (2) of the following conventional conservative techniques (this list in not all inclusive):
  • Behavioral training may include:
    • Bladder training; or
    • Prompted voiding; or
    • pelvic muscle training; or
  • Pharmacological treatment for at least a sufficient duration to fully assess its efficacy; or
  • Surgical corrective therapy; and
• Individual is an appropriate surgical candidate; and
• Incontinence is not related to a neurologic condition.

Permanent implantation of a sacral nerve neuromodulation device may be considered medically necessary in individuals who meet all of the following criteria:

• ALL of the above criteria are met; and
• A trial stimulation period demonstrates at least 50% improvement in symptoms over a period of at least 48 hours.

The following urinary/voiding applications of SNM are considered experimental/investigational and therefore non-covered because the safety and and/or effectiveness of this service cannot be established by the available published peer-reviewed literature, including but not limited to:

• Treatment of stress or urge incontinence due to a neurologic condition for example:
  • Detrusor hyperreflexia; or
  • Multiple sclerosis; or
  • Spinal cord injury; or
  • Other types of chronic voiding dysfunction.

Procedure Codes

Fecal Incontinence

A trial period of SNM with either percutaneous nerve stimulation or a temporarily implanted lead may be considered medically necessary in individuals who meet ALL of the following criteria:

• A diagnosis of chronic fecal incontinence of greater than 2 incontinent episodes on average per week with duration greater than 6 months or for more than 12 months after vaginal childbirth; and
• Individual has failed or has an intolerance to conventional therapy for at least a sufficient duration to fully assess efficacy. This may include but not limited to:
  • dietary modification; or
  • addition of bulking and pharmacologic treatment; and
• The individual has not had rectal surgery in the previous 12 months, or, in the case of cancer, the individual has not had rectal surgery in the past 24 months; and
• The individual is an appropriate surgical candidate; and
• The condition is not related to an anorectal malformation (e.g., congenital anorectal malformation; defects of the external anal sphincter over 60 degrees; visible sequelae of pelvic radiation; active anal abscesses and fistulae) or chronic inflammatory bowel disease; and
• Incontinence is not related to another neurologic condition

Permanent implantation of a sacral nerve neuromodulation device may be considered medically necessary in individuals who meet all of the following criteria:

• ALL of the above criteria have been met; and
• A trial stimulation period demonstrates at least 50% improvement in symptoms over a period of at least 48 hours.

SNM in the treatment of chronic constipation or chronic pelvic pain is considered experimental/investigational, and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

Outpatient HCPCS (C Codes)

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes: A4290, 64561, 64581

Professional Statements and Societal Positions Guidelines

Urinary Disorders

American Urological Association - 2014

The American Urological Association (2014) updated its guidelines on the diagnosis and treatment of overactive bladder. The guidelines stated that sacral neuromodulation may be offered as a third-line treatment in carefully selected individuals with severe refractory symptoms or into those who are not candidates for second-line therapy (e.g., oral antimuscarinics, oral β3-adrenoceptor agonists, transdermal oxybutynin) and are willing to undergo surgery.

American College of Obstetricians and Gynecologists - 2005

A practice bulletin on urinary incontinence from the American College of Obstetricians and Gynecologists (2005) considered sacral nerve neuromodulation to be beneficial for treating chronic voiding dysfunction. An updated 2015 practice bulletin on urinary incontinence from the College did not address sacral nerve stimulation (SNS).

Fecal Disorders

National Institute for Health and Care Excellence - 2007

The National Institute for Health and Care Excellence (2007) issued guidance on the management of fecal incontinence. The guidance was reviewed in 2014, and no changes were made. The guidance has recommended:

• “A trial of temporary sacral nerve stimulation should be considered for people with fecal incontinence in whom sphincter surgery is deemed inappropriate
• All individuals should be informed of the potential benefits and limitations of this procedure and should undergo a trial stimulation period of at least 2 weeks to determine if they are likely to benefit.
• People with fecal incontinence should be offered sacral nerve stimulation on the basis of their response to percutaneous nerve evaluation during specialist assessment, which is predictive of therapy success.”

American College of Gastroenterology - 2014

In its clinical guideline on the management of benign anorectal disorders, including fecal incontinence, the American College of Gastroenterology (2014) found that "sacral nerve stimulation should be considered in [fecal incontinence] who do not respond to conservative therapy."

ND Committee Review

Internal Medical Policy Committee 3-16-2020 revised policy so the trial period requires the criteria to be met

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