C1767, Generator, neurostimulator (implantable), non-rechargeable
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
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.
- Records must document that the condition is not related to excluded causes (anorectal malformation, pelvic radiation sequelae, active anal abscess/fistula, chronic IBD, neurologic causes) when claiming coverage for fecal incontinence.
- Medical record documentation of prior conventional therapies tried and failed (behavioral, pharmacologic and/or surgical) must be provided for urinary indications.
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
PALMETTO-JJ-L39543, Sacral Nerve Stimulation for the Treatment of Urinary and Fecal Incontinence
JJ
PALMETTO-JM-L39543, Sacral Nerve Stimulation for the Treatment of Urinary and Fecal Incontinence
JM
ANTHEM-SURG.00129, SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
ANTHEM-SURG.00158, SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain
ANTHEM-SURG.00112, SURG.00112 Implantation of Occipital, Supraorbital or Trigeminal Nerve Stimulation Devices (and Related Procedures)
ANTHEM-CG-SURG-70, CG-SURG-70 Gastric Electrical Stimulation
ANTHEM-CG-SURG-120, CG-SURG-120 Vagus Nerve Stimulation
AETNA-CPB-0678, Gastric Pacing / Electrical Stimulation and Gastroesophageal Per Oral Endoscopic Myotomy
CIGNA-0391, Diaphragmatic/Phrenic Nerve Stimulation
A53359, Billing and Coding: Sacral Nerve Stimulation for Urinary and Fecal Incontinence
A55835, Billing and Coding: Sacral Nerve Stimulation for Urinary and Fecal Incontinence
A59332, Billing and Coding: Sacral Nerve Stimulation for the Treatment of Urinary and Fecal Incontinence
AETNA-CPB-0788, Alzheimer's Disease: Experimental, Investigational, or Unproven Treatments
AETNA-CPB-0511, Eating Disorders
AETNA-CPB-0614, Huntington's Disease
ANTHEM-CG-SURG-95, CG-SURG-95 Sacral Nerve Stimulation for Urinary Retention, Urinary Incontinence, and Fecal Incontinence
AETNA-CPB-0707, Headaches: Invasive Procedures
AETNA-CPB-0253, Vocal Cord Paralysis / Insufficiency Treatments
AETNA-CPB-0755, Motor Cortex Stimulation
ANTHEM-SURG.00026, SURG.00026 Deep Brain, Cortical, and Cerebellar Stimulation
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.