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    v1.0.30
    OpenPayerPolicy UpdatesGeneral SurgeryAmbetter Nevada Fecal Incontinence Coverage | Open…
    Ask Trek AI about this page
    ModifiedAmbetter NevadaPolicy CP.MP.137

    Fecal Incontinence Treatments

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    Medical necessity and coding support for procedures treating fecal incontinence, including severity requirements, failed conservative treatment, procedure-specific criteria, and treatments considered unproven.

    Policy Summary
    PayerAmbetter Nevada
    PolicyFecal Incontinence Treatments
    Policy CodePolicy CP.MP.137
    Change TypeModified
    Effective DateSep 1, 2026
    Last ReviewMay 1, 2026
    Next Review DateN/A
    Key ActionAttempt and adequately fail conservative treatment, including pharmacotherapy, dietary management, and strengthening exercises, before considering a qualifying procedure.
    SourceLink
    POLICY UPDATE CHANGES

    Added criterion requiring the member or enrollee to demonstrate the ability to use the device and/or comply with follow-up requirements.

    Removed prior sphincteroplasty criteria and criteria addressing inadequate response to test stimulation and absence of physical or mental illness.

    Added CPT 44320 and HCPCS codes C1767 and C1778 to the coding tables during a prior annual review.

    Completed an annual review of codes, references, and policy content.

    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.

    >2/weekSeverity threshold
    >6 monthsRequired duration
    ≥50%Sacral stimulation response
    ≥18 yearsArtificial sphincter minimum age
    3Qualifying treatment options
    6Not-proven-effective procedures

    Medical Necessity and Treatment Criteria

    Medically necessary procedures

    Procedures to treat fecal incontinence are medically necessary when both the baseline condition and one qualifying procedure pathway are met.

    General medical-necessity requirements

    • Severe chronic condition and failed conservative treatment: Severe, chronic fecal incontinence averaging more than two incontinent episodes per week for more than six months, not adequately responsive to conservative treatment such as pharmacotherapy, dietary management, or strengthening exercises, in a member who previously achieved bowel control.>2 episodes/week; >6 months

    • Qualifying procedure

      • Sacral nerve stimulation

        • Positive stimulation trial: A percutaneous stimulation test produces at least 50% sustained symptom improvement for more than one week.≥50% improvement; >1 week
        • Eligible clinical condition: The condition is not related to anorectal malformation, defects of the external anal sphincter over 60 degrees, visible sequelae of pelvic radiation, active anal abscesses or fistulae, or chronic inflammatory bowel disease.
        • No unrelated neurologic cause: The incontinence is not related to another neurologic condition such as peripheral neuropathy or complete spinal cord injury.
        • Device management capability: The member can operate the device or has a supportive caregiver who can provide assistance.
        • No contraindications: There is no mechanical outlet obstruction and no diathermy use, including shortwave, microwave, or ultrasound.

      • Artificial bowel sphincter

        • Age: The member is at least 18 years old.≥18 years
        • Prior treatment failure or ineligibility: Medical interventions have failed or the member is not a candidate for them, and surgical sphincter repair has failed or the member is not a candidate for it.
        • No proximal bowel obstruction: The incontinence is not complicated by an irreversibly obstructed proximal segment of bowel.
      • Colostomy is used as a last resort after all other treatments have failed or are contraindicated.Last resort

    Not proven effective

    The following procedures have not been proven effective for treatment of fecal incontinence.

    Not proven effective: Transanal radiofrequency therapy (Secca procedure); injectable bulking agents such as dextranomer/hyaluronic acid (Solesta); anal electrical stimulation; posterior tibial nerve stimulation; vaginal bowel control such as the Eclipse system; and sacral nerve stimulation for the treatment of chronic constipation or chronic pelvic pain.

    Sacral nerve stimulation is not supported when fecal incontinence is related to anorectal malformation, including congenital anorectal malformation, an external anal sphincter defect over 60 degrees, visible sequelae of pelvic radiation, active anal abscesses or fistulae, chronic inflammatory bowel disease, or another neurologic condition such as peripheral neuropathy or complete spinal cord injury.

    Sacral nerve stimulation is contraindicated in the presence of mechanical outlet obstruction or use of diathermy, including shortwave, microwave, or ultrasound diathermy.

    Artificial bowel sphincter is not supported when fecal incontinence is complicated by an irreversibly obstructed proximal segment of bowel.

    The following treatments have not been proven effective for fecal incontinence: transanal radiofrequency therapy, including the Secca procedure; injectable bulking agents such as dextranomer/hyaluronic acid (Solesta); anal electrical stimulation; posterior tibial nerve stimulation; vaginal bowel control, such as the Eclipse system; and sacral nerve stimulation for chronic constipation or chronic pelvic pain.

    Covered and Non-Covered Codes

    CPT codes that support coverage criteriaCPTCovered
    44320Colostomy or skin level cecostomy.
    46750Sphincteroplasty, anal, for incontinence or prolapse; adult.
    46751Sphincteroplasty, anal, for incontinence or prolapse; child.
    46760Sphincteroplasty, anal, for incontinence, adult; muscle transplant.
    46761Sphincteroplasty, anal, for incontinence, adult; levator muscle imbrication (Park posterior anal repair).
    46999(Park posterior anal repair) Unlisted procedure, anus.
    64561Percutaneous implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) including image guidance, if performed.
    64581Open implantation of neurostimulator electrode array; sacral nerve (transforaminal placement).
    64585Revision or removal of peripheral neurostimulator electrode array.
    64590Insertion or replacement of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pulse generator or receiver.
    1–10 of 14
    1/2
    HCPCS codes that support coverage criteriaHCPCSCovered
    A4290Sacral nerve stimulation test lead, each.
    A4335Incontinence supply; miscellaneous.
    C1767Generator, neurostimulator (implantable), non-rechargeable.
    C1778Lead, neurostimulator (implantable).
    E0745Neuromuscular stimulator, electronic shock unit.
    L8680Implantable neurostimulator electrode, each.
    L8681Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only.
    L8682Implantable neurostimulator radiofrequency receiver.
    L8683Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver.
    L8684Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and bladder management, replacement.
    1–10 of 15
    1/2
    CPT codes that do not support coverage criteriaCPTNot Covered
    No codes listed
    HCPCS codes that support coverage criteriaHCPCSCovered
    A4290Sacral nerve stimulation test lead, each.
    A4335Incontinence supply; miscellaneous.
    C1767Generator, neurostimulator (implantable), non-rechargeable.
    C1778Lead, neurostimulator (implantable).
    E0745Neuromuscular stimulator, electronic shock unit.
    L8680Implantable neurostimulator electrode, each.
    L8681Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only.
    L8682Implantable neurostimulator radiofrequency receiver.
    L8683Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver.
    L8684Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and bladder management, replacement.
    1–10 of 15
    1/2
    CPT codes that do not support coverage criteriaCPTNot Covered
    64566Posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming
    HCPCS codes that do not support coverage criteriaHCPCSNot Covered
    L8605Injectable bulking agent, dextranomer/hyaluronic acid copolymer implant, anal canal, 1 ml, includes shipping and necessary supplies
    Severe chronic fecal incontinence frequency
    Required frequencyMore than two incontinent episodes on average per week
    ConditionSevere, chronic fecal incontinence
    Related requirementThe incontinence must not have responded adequately to conservative treatments
    Severe chronic fecal incontinence duration
    Required durationGreater than six months
    Condition

    Documentation and Request Requirements

    Documentation Required

    Conservative and Anatomic Management First

    Before requesting an advanced procedure, document that conservative treatment was attempted and did not adequately control the incontinence, including pharmacotherapy, dietary management, and strengthening exercises. If fecal incontinence is caused by or associated with an anatomic defect, correct the defect first because correction may improve or eliminate the incontinence.

    • Document the specific conservative therapies tried, duration, adherence, and response.
    • Evaluate and address relevant anatomic defects, such as rectovaginal fistula, rectal prolapse, or hemorrhoidal prolapse, before advanced treatment.
    Documentation Required

    Baseline Condition and Failed Conservative Care

    Document severe, chronic fecal incontinence in a member who previously achieved bowel control and whose symptoms have not responded adequately to conservative treatment.

    • Average frequency: more than two incontinent episodes per week.

    Condition Overview

    Dietary and medical management are generally initial approaches. When anatomic defects such as a rectovaginal fistula or rectal or hemorrhoidal prolapse are present, correcting the defect may improve or eliminate incontinence. Sacral neuromodulation can reduce episode frequency, while sphincteroplasty may be considered for a defined external anal sphincter defect.

    Policy Terms

    Fecal incontinence
    DefinitionUncontrolled passage of feces
    Minimum durationAt least three months
    Prior bowel controlThe individual previously achieved control
    Severe, chronic fecal incontinence
    FrequencyMore than two incontinent episodes on average per week
    DurationGreater than six months
    Clinical classificationSevere, chronic fecal incontinence
    Policy Summary
    PayerAmbetter Nevada
    PolicyFecal Incontinence Treatments
    Policy CodePolicy CP.MP.137
    Change TypeModified
    Effective DateSep 1, 2026
    Last ReviewMay 1, 2026
    Next Review DateN/A
    Key ActionAttempt and adequately fail conservative treatment, including pharmacotherapy, dietary management, and strengthening exercises, before considering a qualifying procedure.
    SourceLink
    On This Page
    Medical Necessity and Treatment CriteriaCovered and Non-Covered CodesDocumentation and Request RequirementsCondition OverviewPolicy Terms
    Severe, chronic fecal incontinence
    Prior bowel controlThe member must have previously achieved bowel control
    Sacral stimulation test response
    Test methodPercutaneous stimulation test before implantation
    Required responseAt least 50% sustained improvement in symptoms
    Minimum response durationMore than one week
    Artificial bowel sphincter age
    Minimum ageAt least 18 years old
    ProcedureArtificial bowel sphincter (Acticon Neosphincter)
    Additional requirementMedical interventions or surgical sphincter repair must have failed, or the member must not be a candidate for them
  1. Duration: more than six months.
  2. Include prior bowel control and the inadequate response to conservative care.
    3. Documentation Required

    Sacral Stimulation Trial and Suitability

    For sacral nerve stimulation (sacral neuromodulation), document a weak but structurally intact anal sphincter and a successful percutaneous stimulation trial showing at least 50% sustained improvement for more than one week.

    • Exclude anorectal malformation, external anal sphincter defects over 60 degrees, visible sequelae of pelvic radiation, active anal abscesses or fistulae, and chronic inflammatory bowel disease.
    • Confirm that incontinence is not attributable to peripheral neuropathy, complete spinal cord injury, or another neurologic condition.
    • Document the member’s ability to operate the device or the availability of a supportive caregiver.
    • Confirm no mechanical outlet obstruction and no diathermy use, including shortwave, microwave, or ultrasound.

    Unsupported block type: documentation

    Documentation Required

    Colostomy as a Last Resort

    Colostomy may be requested only as a last resort after all other treatments have failed or are contraindicated.

    • Document the prior treatments considered or attempted and their outcomes.
    • Identify any contraindications that prevent use of alternative treatments.
    Denial Risk

    Insufficient Severity, Duration, or Conservative-Treatment Failure

    Coverage is at risk when the record does not establish the required baseline severity, chronicity, prior bowel control, and failure of conservative treatment.

    • Fewer than or equal to two incontinent episodes per week does not meet the stated severity threshold.
    • Incontinence lasting six months or less does not meet the stated duration threshold.
    • Do not omit documentation of previously achieved bowel control or inadequate response to pharmacotherapy, dietary management, and strengthening exercises.
    Denial Risk

    Procedure-Specific Criteria Not Met

    Coverage is at risk when the requested procedure does not meet its procedure-specific criteria. For sacral stimulation, a qualifying percutaneous trial with at least 50% sustained improvement for more than one week is required in addition to the applicable suitability and contraindication review.

    • Sacral stimulation requires a weak but structurally intact anal sphincter and compliance with the listed anatomic, neurologic, device-use, and contraindication requirements.
    • Artificial bowel sphincter requests require age 18 or older, failed or unsuitable medical or surgical intervention, and no irreversibly obstructed proximal bowel segment.
    • Colostomy requires documentation that all other treatments failed or were contraindicated.
    Denial Risk

    Procedures Not Proven Effective

    The policy states that several procedures have not been proven effective for treatment of fecal incontinence and therefore do not support coverage under these criteria.

    • Transanal radiofrequency therapy (Secca procedure).
    • Injectable bulking agents, including dextranomer/hyaluronic acid (Solesta).
    • Anal electrical stimulation.
    • Posterior tibial nerve stimulation.
    • Vaginal bowel control, including the Eclipse system.
    • Sacral nerve stimulation for chronic constipation or chronic pelvic pain.
    Billing Rule

    Codes Not Supporting Coverage Criteria

    Claims using the following codes do not support the policy’s coverage criteria for fecal incontinence treatments.

    • CPT 64566: Posterior tibial neurostimulation, percutaneous needle electrode, single treatment, including programming.
    • HCPCS L8605: Injectable bulking agent, dextranomer/hyaluronic acid copolymer implant, anal canal, 1 mL, including shipping and necessary supplies.
    Sacral nerve stimulation
    ProcedureSacral nerve stimulation
    Alternate termSacral neuromodulation
    Required preliminary testA test of percutaneous stimulation is performed before implantation