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.
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:
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:
SNS/SNM may be considered medically necessary for the treatment of fecal incontinence when ALL of the following criteria are met:
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.
Covered Diagnosis Codes for Procedure Codes: 64561 and 64581