T85.734S — Infection and inflammatory reaction due to implanted electronic neurostimulator, generator, sequela
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Claims must be supported by medical record documentation demonstrating that the service meets the LCD L39543 indications and limitations and general CMS medical necessity requirements.
- Record of test stimulation results (temporary/percutaneous test), including quantitative improvement percentage, must be submitted to support permanent implantation.
- Documented evidence of failure or intolerance of conventional therapies (behavioral therapies, dietary modification, bulking agents, pharmacologic treatment, and/or surgical corrective therapy) is required.
- Voiding diaries or bowel symptom diaries must be maintained and used to measure test stimulation improvement (≥50% improvement for urinary indications and sustained ≥50% improvement >48 hours for FI).
Key Coverage Criteria
- Services for sacral nerve stimulation are covered only when they meet all indications specified in Local Coverage Determination L39543 for treatment of urinary and/or fecal incontinence.
- Coverage requires compliance with general CMS medical necessity requirements and any applicable National Coverage Determinations (NCDs) and Medicare payment rules.
- SNS is covered for treatment of urinary urge incontinence.
- SNS is covered for treatment of urgency-frequency syndrome (urgency with frequency).
- SNS is covered for treatment of nonobstructive urinary retention.
- SNS is covered for fecal incontinence when all required criteria are met: chronic FI with >2 incontinent episodes per week and duration >6 months (or >12 months after vaginal childbirth); documented failure or intolerance of conventional therapy; and a successful percutaneous test stimulation (≥50% sustained improvement >48 hours).
2 Active Policies
A59332 — Billing and Coding: Sacral Nerve Stimulation for the Treatment of Urinary and Fecal Incontinence
L39543 — Sacral Nerve Stimulation for the Treatment of Urinary and Fecal Incontinence
Related Codes
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