0786T — Insj/rplcmt prq ra sac nstim
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- General statement: "Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested; refer to the guidelines titled Medical Records Documentation Used for Reviews."
- Evidence of age: documentation that individual is ≥ 18 years of age.
- For urinary indications: documentation of lower urinary tract symptoms (one or more listed: overactive bladder symptoms, urge incontinence, nonobstructive urinary retention).
- Bladder capacity documentation: objective documentation that bladder capacity is 100 ml or greater.
Key Coverage Criteria
- - Improvement in reported symptoms of 50% or greater in response to a screening trial of Sacral Nerve Stimulation
- Note: This policy applies to individuals ≥ 18 years of age.
- Sacral Nerve Stimulation (neurostimulation) screening trial is proven and medically necessary for treating urinary voiding dysfunction when all the following criteria are met:
- - Lower urinary tract symptoms, as indicated by one or more of the following: - Overactive bladder symptoms (also known as urgency frequency syndrome) - Urge Incontinence - Nonobstructive urinary retention (NOUR)
- - Bladder capacity of 100 ml or greater
- - Urinary voiding dysfunction is not secondary to a neurologic disease origin [e.g., Parkinson's disease, stroke, spinal cord injury, multiple sclerosis (MS)]
3 Active Policies
UHC-POL-sacral-nerve-stimulation — Sacral Nerve Stimulation for Urinary and Fecal Indications
UMR-POL-UMR-sacral-nerve-stimulation — Sacral Nerve Stimulation for Urinary and Fecal Indications
SUREST-POL-SUREST-sacral-nerve-stimulation — Sacral Nerve Stimulation for Urinary and Fecal Indications
Related Codes
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