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Coverage criteria policies

Sacral nerve stimulation for fecal incontinence

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is not required for sacral nerve stimulation for fecal incontinence.

Coverage

Sacral nerve stimulation for fecal incontinence is generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

  1. Chronic fecal incontinence with greater than two incontinent episodes on average per week and duration of incontinence greater than six months or for more than twelve months after vaginal childbirth; AND
  2. Documented failure or intolerance to conventional therapy (e.g., dietary modification, the addition of bulking and pharmacologic treatment); AND
  3. A successful percutaneous test stimulation, defined as at least 50% sustained (more than one week) improvement in symptoms; AND
  4. Condition is not related to anorectal malformation (e.g., congenital anorectal malformation; defects of the external anal sphincter over 60 degrees; visible sequelae of pelvic radiation; active anal abscesses and fistulae) and/or chronic inflammatory bowel disease; AND
  5. Incontinence is not related to another neurologic condition such as peripheral neuropathy or complete spinal cord injury.

Indications that are not covered

Sacral nerve stimulation is considered experimental/investigational for the following indications, including, but not limited to:

  1. treatment of chronic constipation
  2. chronic pelvic pain

Definition

Sacral nerve stimulation, also called sacral nerve modulation, involves the application of a mild electrical pulse to the sacral nerves through a surgically implanted neuromodulation system to treat fecal incontinence. The electrical pulses modulate the sacral nerves that influence the functioning of the bladder, bowel, urinary, and anal sphincters, and the pelvic floor muscles. The InterStim Therapy System is manufactured by Medtronic.

If available, codes for a procedure, device or diagnosis are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all inclusive.

Codes

Description

64561

Percutaneous implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) including image guidance, if performed

64581

Incision for implantation of neurostimulator electrode array; sacral nerve (transforaminal placement)

64590

Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

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Policy activity

  • 07/20/2012 - Date of origin
  • 08/09/2012 - Effective date
Review date
  • 07/2015

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