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.
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:
Permanent implantation of a sacral nerve neuromodulation device may be considered medically necessary in individuals who meet all of the following criteria:
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:
64561 | 64581 | 64585 | 64590 | 64595 | 95970 | 95971 |
95972 | A4290 | E0745 | E1399 | L8680 | L8681 | L8685 |
L8686 | L8687 | L8688 |
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:
Permanent implantation of a sacral nerve neuromodulation device may be considered medically necessary in individuals who meet all of the following criteria:
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.
64561 |
64581 |
64585 |
64590 |
64595 |
95970 |
95971 |
95972 |
A4290 |
E0745 |
E1399 |
L8680 |
L8681 |
L8685 |
L8686 |
L8687 |
L8688 |
C1767 | C1778 | C1816 | C1883 | C1897 |
Covered Diagnosis Codes for Procedure Codes: A4290, 64561, 64581
N32.81 | N39.41 | R15.0 | R15.1 | R15.2 | R15.9 | R33.0 |
R33.8 | R33.9 | R35.0 |
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:
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."
Internal Medical Policy Committee 3-16-2020 revised policy so the trial period requires the criteria to be met