C1883, Adapter/extension, pacing lead or neurostimulator lead (implantable)
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high 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
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-0511, Eating Disorders
AETNA-CPB-0614, Huntington's Disease
AETNA-CPB-0707, Headaches: Invasive Procedures
AETNA-CPB-0253, Vocal Cord Paralysis / Insufficiency Treatments
AETNA-CPB-0755, Motor Cortex Stimulation
AETNA-CPB-0362, Spasticity Management
AETNA-CPB-0406, Tinnitus Treatments
AETNA-CPB-0374, Trigeminal Neuralgia: Treatments
AETNA-CPB-0191, Vagus Nerve Stimulation
AMBETTER-CP.MP.12, Vagus Nerve Stimulation
BCBSIL-MED205.042, Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions
BCBSIL-SUR712.009, Spinal Cord Stimulation (SCS) and Dorsal Root Ganglion (DRG) Stimulation
BCBSMT-MED205.042, Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions
BCBSMT-SUR712.009, Spinal Cord Stimulation (SCS) and Dorsal Root Ganglion (DRG) Stimulation
BCBSNM-MED205.042, Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions
Related Codes
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