S1094
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- There are complications such as, but not limited to, infection or implant site pain.
- The device has been determined to be an ineffective treatment for the individualâs symptoms;or
- There are complications such as, but not limited to, infection or implant site pain.
- Removal of an implanted sacral nerve stimulator is consideredmedically necessarywhen any of the following have been met:
- The device is no longer functioning appropriately;or
- A trial or temporary sacral nerve stimulator is consideredmedically necessarywhen the following criteria are met (AandB):
1 Active Policy
ANTHEM-CG-SURG-95 — CG-SURG-95 Sacral Nerve Stimulation for Urinary Retention, Urinary Incontinence, and Fecal Incontinence
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.