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Sacral Nerve Neuromodulation/Stimulation

Section: Surgery
Effective Date: July 01, 2018
Revised Date: November 14, 2019
Last Reviewed: November 14, 2019

Description

Sacral nerve stimulation (SNS), also referred to as 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

Coverage is subject to the specific terms of the member’s benefit plan.

SNS/SNM (e.g., InterStim Continence Control Therapy System), may be considered medically necessary when ALL of the following criteria are met:

  • The individual has a diagnosis of ONE of the following: 
    • Urinary urge incontinence; or
    • Urgency-frequency; or
    • Non-obstructive urinary retention; or
    • Overactive bladder not resulting from a neurologic condition; and
  • The individual has a diagnosis of urinary urge incontinence, urgency-frequency, non-obstructive urinary retention, or overactive bladder that is not due to a neurologic condition; and 
  • Symptoms of urinary urge incontinence, urgency-frequency, non-obstructive urinary retention, or overactive bladder have been present for at least one year's duration and have resulted in significant disability (e.g., the urgency-frequency and/or severity of leakages, or urinary retention are limiting the patient's ability to work or participate in activities outside the home); and 
  • The individual has tried and failed the following conservative treatments: 
    • Pharmacological - e.g., two different anticholinergic drugs (such as oxybutynin and hyoscyamine) or a combination of an anticholinergic and a tricyclic antidepressant (such as imipramine); and
    • Behavioral - e.g., pelvic muscle exercise, biofeedback, timed voids, and fluid management; and
  • A trial period of SNS/SNM with either percutaneous nerve stimulation or a temporarily implanted lead has provided at least a 50% reduction in incontinence symptoms or a 50% reduction in residual urine volume.

Other urinary/voiding applications of SNS/SNM including, but not limited to treatment of the following, are 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:

  • Urinary urge incontinence due to a neurologic condition (e.g., detrusor hyperreflexia, multiple sclerosis, spinal cord injury);
  • Stress incontinence;
  • Other types of chronic voiding dysfunction.

Procedure Codes

64561 64581 64585 64590 64595 95970 95971
95972 A4290 E0745 E1399 L8680 L8681 L8685
L8686 L8687 L8688

Outpatient HCPCS (C Codes)

C1767 C1778 C1816 C1883 C1897

SNS/SNM may be considered medically necessary for the treatment of fecal incontinence when ALL of the following criteria are met:

  • 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
  • Documented failure or intolerance to conventional therapy (e.g., dietary modification, the addition of bulking and pharmacologic treatment for at least a sufficient duration to fully assess its efficacy; and
  • There has been no rectal surgery in the previous 12 months, or 24 months in case of cancer; and
  • The individual is an appropriate surgical candidate; and
  • A trial period of SNS/SNM with either percutaneous nerve stimulation or a temporarily implanted lead, defined as at least 50% improvement in symptoms over a period of at least 48 hours, was performed; 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 such as peripheral neuropathy or complete spinal cord injury.

SNS/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

64561 64581 64585 64590 64595 95970 95971
95972 A4290 E0745 E1399 L8680 L8681 L8685
L8686 L8687 L8688

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes: 64561 and 64581

N32.81 N39.41 R15.0 R15.1 R15.2 R15.9 R33.0
R33.8 R33.9 R35.0

Professional Statements and Societal Positions Guidelines

NA

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