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    v1.0.28
    OpenPayerPolicy UpdatesGastroenterologyAmbetter Nevada Fecal Incontinence Coverage Update…
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    CurrentAmbetter NevadaPolicy CP.MP.137

    Clinical Policy: Fecal Incontinence Treatments

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    Medical necessity and coverage guidance for procedures and therapies to treat fecal incontinence for Ambetter Nevada members; intended for providers submitting requests and claims.

    Policy Summary
    PayerAmbetter Nevada
    PolicyFecal Incontinence Treatments
    Policy CodePolicy CP.MP.137
    Change TypeCriteria updatescoding additions/removals
    Effective Date
    Next Review Date
    Key ActionObtain prior authorization and document guideline‑based indications including prior achievement of bowel control when submitting requests for listed procedural codes.
    SourceLink
    POLICY UPDATE CHANGES

    Removed '≥ 4 years age' criteria

    Added requirement 'in a member/enrollee that has previously achieved bowel control' to I.A.

    Removed 'more than twelve months after vaginal childbirth' from the definition of severe, chronic fecal incontinence in I.A.

    Added criteria I.B.1.d. 'Member/enrollee demonstrates the ability…' and removed certain prior test stimulation and mental/physical illness criteria.

    Added CPT 44320 and HCPCS C1767, C1778 to coding tables.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    2018–2025policy reviewed/updated
    6+codes referenced
    30+references cited

    Coverage and Medical Necessity Criteria

    Updated eligibility and evaluation criteria

    Covered when the following updated eligibility and pre-procedure evaluation criteria are met:

    Eligibility modifications (I.A): Member/enrollee must have previously achieved bowel control (new requirement); the prior age threshold (≥ 4 years) has been removed; timing 'more than twelve months after vaginal childbirth' has been removed from the definition of severe, chronic fecal incontinence.

    These changes affect who is eligible for covered treatments.

    Evaluation criteria changes (I.B): Pre-procedure candidate evaluation updated: added I.B.1.d. requiring that the member/enrollee demonstrates the ability (specifics detailed in the clinical evaluation section of the policy); removed I.B.1.e.iii. regarding 'inadequate response to test stimulation' and removed I.B.3.d. requiring 'absence of any physical or mental illness'. Previous criterion I.B.2. for sphincteroplasty was removed.

    Alters pre-authorization evaluation, candidate selection, and suitability for advanced interventions such as sacral neuromodulation.

    The following CPT and HCPCS codes are identified in the policy as not supporting coverage criteria: 46760, 46761, 64581, 64590, and L8683.

    Procedures billed using the CPT/HCPCS codes listed as not supporting coverage criteria may be considered not medically necessary if the applicable policy conditions and coverage criteria are not met at the time of service.

    Billing Codes and Coding Guidance

    Codes added/flagged in policy textmixed
    46760CPT code referenced as not supporting coverage criteria
    46761CPT code referenced as not supporting coverage criteria
    64581CPT code referenced as not supporting coverage criteria
    64590CPT code referenced as not supporting coverage criteria
    L8683HCPCS code referenced as not supporting coverage criteria
    44320CPT code added to coding tables
    C1767HCPCS code added to coding tables
    C1778HCPCS code added to coding tables
    Referenced CMS coverage articlesmixed
    Local coverage article A53017CMS billing and coding: sacral nerve stimulation for urinary and fecal incontinence
    Local coverage determination L39543CMS LCD: sacral nerve stimulation for urinary and fecal incontinence

    Provider Requirements, Prior Authorization, and Documentation

    Prior Authorization

    Prior Authorization Required

    Prior authorization is required for the procedural codes listed in the policy. Submit a prior authorization request with clinical documentation that demonstrates the member meets all guideline-based evaluation criteria before scheduling advanced or implantable therapies.

    • Affected CPT codes: 44320 (added to coding tables).
    • Prior authorization applies to advanced device/procedural interventions described in policy I.B (including implantable therapies).
    Denial Risk

    Unsupported HCPCS/CPT Codes — Denial Risk

    The following HCPCS/CPT codes do not support coverage under the criteria of this policy and may lead to claim denials if billed as the primary justification: CPT 46760, CPT 46761, CPT 64581, CPT 64590, and HCPCS L8683. Use of these codes alone is insufficient to meet medical necessity.

    Key Definitions and Terms

    Previously achieved bowel control
    New eligibility requirementMember/enrollee must have previously achieved bowel control (added to I.A.).
    Where statedRequirement added to I.A. of the policy as part of the 07/23 and 06/24 revisions.
    PurposeRestricts eligibility for certain fecal incontinence treatments to members who had prior ability to control bowel function.
    Documentation implicationClinical documentation should demonstrate prior bowel control when submitting for authorization or coverage review.
    Severe, chronic fecal incontinence (definition change)
    Definition changeRemoved the timing phrase 'more than twelve months after vaginal childbirth' from the definition of 'severe, chronic fecal incontinence' in I.A.

    Background and Treatment Overview

    Management options for fecal incontinence discussed in the policy include conservative and behavioral therapies, injectable bulking agents, neuromodulation (including sacral neuromodulation), temperature-controlled radiofrequency procedures, and surgical options. The policy references guideline and trial evidence (for example, sacral neuromodulation and injectable agents) to inform coverage determinations and to define candidate evaluation and sequencing of therapies.

    Policy Summary
    PayerAmbetter Nevada
    PolicyFecal Incontinence Treatments
    Policy CodePolicy CP.MP.137
    Change TypeCriteria updatescoding additions/removals
    Effective Date
    Next Review Date
    Key ActionObtain prior authorization and document guideline‑based indications including prior achievement of bowel control when submitting requests for listed procedural codes.
    SourceLink
    On This Page
    Coverage and Medical Necessity CriteriaBilling Codes and Coding GuidanceProvider Requirements, Prior Authorization, and DocumentationKey Definitions and TermsBackground and Treatment Overview
  1. CPT 46760
  2. CPT 46761
  3. CPT 64581
  4. CPT 64590
  5. HCPCS L8683
    6. Documentation Required

    Clinical Documentation to Support Medical Necessity

    Document clinical necessity clearly in the prior authorization and medical record. Documentation should align with guideline-based indications and include objective findings, previous conservative therapies attempted, and, when required by criteria, evidence that the member previously achieved bowel control.

    • Include history of symptom duration, severity, and impact on function.
    • List conservative treatments tried (e.g., dietary measures, biofeedback, medications) with dates and responses.
    • If applicable, document prior bowel control (e.g., developmental history or prior continence) when the criteria require it.
    Step Therapy

    Evaluation Steps Before Advanced Therapies

    Before authorizing advanced therapies (including implantable devices), complete the required evaluation steps and document them: confirm conservative therapy failure, perform guideline-based assessment, and verify the member meets all specified candidacy criteria in I.B.1 (including any new requirement that the member demonstrates the ability related to treatment). Older prerequisites removed from policy (e.g., prior test-stimulation failure, sphincteroplasty-specific criteria) are no longer required.

    • Confirm failure of appropriate conservative management.
    • Perform objective assessment per guideline recommendations (including anorectal testing if specified by policy).
    • Document that the member meets updated I.B.1.d candidate abilities and other current exclusion/inclusion criteria.
    • Do not require previously removed items such as mandatory test-stimulation failure or prior sphincteroplasty criteria unless separately specified.
    Revision timelineChange recorded in the 07/23 and 06/24 policy revisions and reflected in subsequent annual reviews.
    Effect on severity criterionSeverity no longer depends on a specific interval after vaginal childbirth; wording deleted from I.A. definition.
    Clinical impactClarifies that the severity classification is not limited by the prior childbirth timing clause previously included.