64561
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
5.30
Facility
$271.22
Non-Facility
$742.84
Documentation Required
- Voiding diaries documenting baseline and test-stimulation outcomes are required to measure the ≥50% improvement for urinary indications.
- For fecal incontinence, documentation must show frequency (>2 incontinent episodes/week), duration (>6 months or >12 months after vaginal childbirth), and failure or intolerance of conventional therapies.
- A percutaneous test stimulation report documenting at least 50% sustained (>1 week) improvement is required to support permanent implantation for fecal incontinence.
- Medical records must document that the patient is refractory to conventional therapy (behavioral, pharmacologic and/or surgical) for urinary indications and is an appropriate surgical candidate able to undergo anesthesia.
Key Coverage Criteria
- Sacral nerve stimulation (SNS) is covered for urinary urge incontinence.
- SNS is covered for urgency-frequency syndrome (urinary urgency-frequency).
- SNS is covered for urinary retention.
- Both a temporary test stimulation and subsequent permanent implantation of an implanted sacral electrode array are covered for appropriate candidates.
- SNS is covered for fecal incontinence when all fecal-specific criteria are met (see limitations/frequency): chronic fecal incontinence with >2 incontinent episodes/week and duration >6 months or >12 months after vaginal childbirth.
- Coverage for fecal incontinence requires documented failure or intolerance to conventional therapy (e.g., dietary modification, bulking agents, pharmacologic treatment).
20 Active Policies
NORIDIAN-L34328 — Peripheral Nerve Stimulation
JF Part B
PALMETTO-L39543 — Sacral Nerve Stimulation for the Treatment of Urinary and Fecal Incontinence
JJ Part B
AETNA-CPB-0679 — Levator Syndrome Treatments
UHC-POL-sacral-nerve-stimulation — Sacral Nerve Stimulation for Urinary and Fecal Indications
A53359
Related Codes
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