C1883 — Adapter/extension, pacing lead or neurostimulator lead (implantable)
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.
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
AMBETTER-CP.MP.12 — Vagus Nerve Stimulation
CIGNA-0391 — Diaphragmatic/Phrenic Nerve Stimulation - (0391)
AETNA-CPB-0191 — Vagus Nerve Stimulation
AETNA-CPB-0253 — Vocal Cord Paralysis / Insufficiency Treatments
AETNA-CPB-0362 — Spasticity Management
Related Codes
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