46760
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
17.01
Facility
$1048.79
Non-Facility
$1048.79
Documentation Required
- Record of frequency/duration of fecal incontinence demonstrating >2 episodes/week and duration >6 months.
- Documentation of prior conservative treatments tried (pharmacotherapy, dietary measures, pelvic floor strengthening) and inadequate response.
- Evidence that patient previously achieved bowel control.
- Documentation that anal sphincter is structurally intact (clinical exam, imaging, or other objective assessment).
Key Coverage Criteria
- Severe, chronic fecal incontinence defined as >2 incontinent episodes per week on average and duration >6 months.
- Failure of adequate conservative treatments (e.g., pharmacotherapy, dietary management, pelvic floor strengthening exercises).
- Patient previously achieved bowel control (not congenital loss of bowel control).
- Sacral nerve stimulation for a weak but structurally intact anal sphincter when a percutaneous stimulation test produced at least a 50% sustained (>1 week) improvement in symptoms.
- Artificial bowel sphincter (Acticon Neosphincter) for adults age ≥ 18 years when all criteria below are met
- Failure of, or not a candidate for, medical interventions or surgical sphincter repair
1 Active Policy
AMBETTER-CP.MP.137 — Fecal Incontinence Treatments
Related Codes
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