CG-SURG-95 Sacral Nerve Stimulation for Urinary Retention, Urinary Incontinence, and Fecal Incontinence

This policy addresses sacral nerve stimulation (sacral neuromodulation), including trial/temporary systems, for urinary urge incontinence, urinary urgency/frequency, non‑obstructive urinary retention, and fecal incontinence. A trial or temporary device is medically necessary when policy criteria A and B are met, including the presence of eligible non‑neurogenic urinary conditions (urge incontinence, urgency/frequency, or non‑obstructive urinary retention); SNS for these urinary indications is not covered when these criteria are not met. SNS is not medically necessary for neurogenic bladder due to spinal cord injury, for self‑activated anterior sacral root stimulation, and for fecal incontinence when policy criteria are not met.

"A trial or temporary sacral nerve stimulator is consideredmedically necessarywhen the following criteria are met (AandB):"

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