ModifiedArizona Complete HealthPolicy CP.MP.137

Fecal Incontinence Treatments

Defines medical necessity and non-covered procedures for treatments of fecal incontinence for members/enrollees of Arizona Complete Health (Centene-affiliated health plans). Applies to providers requesting authorization for procedural interventions.

Policy Summary

PayerArizona Complete Health

PolicyFecal Incontinence Treatments

Policy CodePolicy CP.MP.137

Change TypeCriteria additions/removalscoding updates

Effective Date

Next Review Date

Key ActionObtain prior authorization and document severe, chronic fecal incontinence, prior conservative therapy, and successful test stimulation when requesting sacral neuromodulation.

SourceLink

POLICY UPDATE CHANGES

Added criterion that member/enrollee demonstrates the ability to operate the device or has a supportive caregiver.

Removed previous criterion requiring inadequate response to test stimulation (I.B.1.e.iii).

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

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…

Removed previous criteria I.B.2. for sphincteroplasty.

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

>=2/week & >6 monthsdefinition of severe, chronic fecal incontinence

>=50%

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Coverage Criteria and Procedural Indications

Initial procedural coverage

Covered when ALL of the following are met:

General eligibility: Member/enrollee has severe, chronic fecal incontinence (greater than two incontinent episodes on average per week and duration > six months) who previously achieved bowel control; and has not responded adequately to conservative treatments (e.g., pharmacotherapy, dietary management, strengthening exercises).

From I.A

Requested procedure meets one of the following: Requested procedure is sacral nerve stimulation, artificial bowel sphincter (Acticon Neosphincter), or colostomy as last resort, each with its own subcriteria.

From I.B

Sacral nerve stimulation (sacral neuromodulation)

SNS is medically necessary when ALL of the following are met

SNS specific: Anal sphincter is weak but structurally intact; a test of percutaneous stimulation was effective, defined as at least 50% sustained (more than one week) improvement in symptoms; condition is not related to anorectal malformation or chronic inflammatory bowel disease; incontinence is not related to another neurologic condition such as peripheral neuropathy or complete spinal cord injury; member/enrollee demonstrates the ability to operate the device or has a supportive caregiver; and none of the following contraindications are present: mechanical outlet obstruction; diathermy use (shortwave, microwave, ultrasound).>= 50% sustained improvement (more than one week)

I.B.1 with additions per revision history

Artificial bowel sphincter (Acticon Neosphincter)

Acticon Neosphincter is medically necessary when ALL of the following are met

Artificial bowel sphincter: Age ≥ 18 years; failure of, or not a candidate for, medical interventions or surgical sphincter repair; and incontinence is not complicated by an irreversibly obstructed proximal segment of bowel.

I.B.2

Colostomy

Colostomy coverage

Colostomy may be considered when all other treatments have failed or are contraindicated (reserved as a last resort).

I.B.3

Revised eligibility and definition criteria (I.A)

Policy revisions affecting existing criteria include:

I.A eligibility modifications: Removed age ≥ 4 years; added requirement 'member/enrollee that has previously achieved bowel control' and removed 'more than twelve months after vaginal childbirth' from the definition of severe, chronic fecal incontinence.

Changes documented in revision history.

Procedural criteria updates (I.B)

Procedure-specific criteria changes:

I.B procedural criteria: Added I.B.1.d requiring that the member/enrollee demonstrates the ability to operate the device or has a supportive caregiver; removed I.B.1.e.iii (inadequate response to test stimulation) and removed previous I.B.2 for sphincteroplasty. Coding table entries (e.g., CPT 44320, HCPCS C1767, C1778) were added per revision history.

See revision history for exact wording.

The policy identifies specific procedures that are considered not proven effective for the treatment of fecal incontinence and therefore excluded from coverage. These include transanal radiofrequency therapy (Secca), injectable bulking agents (for example, dextranomer/hyaluronic acid [Solesta]), anal electrical stimulation, posterior tibial nerve stimulation, vaginal bowel control systems (e.g., the Eclipse system), and sacral nerve stimulation when used for chronic constipation or chronic pelvic pain. The background discussion notes limited, small, or short-to-mid term evidence for several of these modalities, supporting their listing as not proven effective.

The policy calls out specific CPT and HCPCS codes that do not support coverage criteria and may be excluded or require additional justification. Examples listed explicitly are CPT 46760, CPT 46761, CPT 64581, CPT 64590 and HCPCS L8683. The revisions section also notes the addition of codes to the coding tables (for example, CPT 44320 and HCPCS C1767, C1778), underscoring the need to verify codes submitted for prior authorization against the current coding tables.

The policy explicitly states that the procedures listed have not been proven effective for the treatment of fecal incontinence and therefore are considered not medically necessary under this policy when used for that indication. The document cites limited or low-quality evidence for injectable bulking agents and transanal radiofrequency, and notes small, short- or mid-term studies for devices such as the Eclipse system, supporting the determination that these procedures are not proven.

The revision history documents that certain criteria and related items were removed from the policy and are no longer supported. Notably, the policy removed the previous sphincteroplasty criteria I.B.2, and revisions removed criteria related to inadequate response to test stimulation (I.B.1.e.iii). These removals mean sphincteroplasty-specific coverage logic present in prior versions is no longer part of the current criteria set, and billing or authorization requests relying on those removed criteria should be reassessed against the updated policy requirements and coding tables.

Coding Tables and Stated Code Lists

CPT codes that support coverage criteriaCPTCovered

44320	Colostomy or skin level cecostomy.
46750	Sphincteroplasty, anal, for incontinence or prolapse; adult.
46751	Sphincteroplasty, anal, for incontinence or prolapse; child.
46760	Sphincteroplasty, anal, for incontinence, adult; muscle transplant.
46761	Sphincteroplasty, anal, for incontinence, adult; levator muscle imbrication (Park posterior anal repair).
46999	Unlisted procedure, anus.
64561	Percutaneous implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) including image guidance, if performed.
64581	Open implantation of neurostimulator electrode array; sacral nerve (transforaminal placement).
64585	Revision or removal of peripheral neurostimulator electrode array.
64590	Insertion 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

A4290	Sacral nerve stimulation test lead, each.
A4335	Incontinence supply; miscellaneous.
C1767	Generator, neurostimulator (implantable), non-rechargeable.
C1778	Lead, neurostimulator (implantable).
E0745	Neuromuscular stimulator, electronic shock unit.
L8680	Implantable neurostimulator electrode, each.
L8681	Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only.
L8682	Implantable neurostimulator radiofrequency receiver.
L8683	Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver.
L8684	Radiofrequency 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

64566

Posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming

HCPCS codes that do not support coverage criteriaHCPCSNot Covered

L8605

Injectable bulking agent, dextranomer/hyaluronic acid copolymer implant, anal canal, 1 ml, includes shipping and necessary supplies

HCPCS/CPT codes noted in revisions (unsupported and added)mixed

46760	CPT code listed as not supported in HCPCS codes that do not support coverage criteria
46761	CPT code listed as not supported in HCPCS codes that do not support coverage criteria
64581	CPT code listed as not supported in HCPCS codes that do not support coverage criteria
64590	CPT code listed as not supported in HCPCS codes that do not support coverage criteria
L8683	HCPCS code listed as not supporting coverage criteria
44320	CPT code added to coding tables per revision
C1767	HCPCS code added to coding tables per revision
C1778	HCPCS code added to coding tables per revision

inv-16: Test stimulation response — >= 50% sustained improvement (more than one week)

Threshold>= 50% sustained improvement (more than one week)

Measurement periodSustained improvement measured for more than one week during percutaneous test stimulation

Clinical meaningIndicates effective percutaneous sacral stimulation test supporting progression to implantable sacral neuromodulation

Provider Requirements, Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for procedural and device codes that support coverage criteria. Prior authorization requests must include the specific procedure and device codes and clinical rationale demonstrating that the member meets policy criteria for severe, chronic fecal incontinence and prior conservative management.

Affected procedures and devices require prior authorization before scheduling or implantation.
Include proposed CPT/HCPCS codes and device model when applicable.

Billing Rule

Code Verification and Prior Authorization

Verify CPT and HCPCS codes against the plan’s current coding tables prior to submission. Some codes do not support coverage criteria and their use may lead to denial of the request.

Definitions and Key Clinical Thresholds

Fecal incontinence is generally defined in this policy as the uncontrolled passage of feces occurring over a sustained period and significantly impairing quality of life. The policy identifies severe, chronic fecal incontinence as occurring in individuals who previously achieved bowel control and experience an average of greater than two incontinent episodes per week for a duration of more than six months. The background emphasizes that treatment selection depends on etiology and sphincter anatomy, that initial management should include dietary and medical measures, and that many interventional options have modest benefit with limited long-term evidence.

inv-26: Severe, chronic fecal incontinence — >2 incontinent episodes per week and duration >6 months

Episode frequency>2 incontinent episodes per week on average

Duration>6 months

Prior bowel controlApplies to individuals who previously achieved bowel control

inv-27: Test stimulation response — Effective percutaneous sacral stimulation test: >=50% sustained (more than one week) improvement

Revision History and Material Changes

2026-06-24 (Approval Date noted as 06/24 in source)material_revision

Added criterion I.B.1.d requiring member/enrollee demonstrates ability to operate device or has supportive caregiver; removed I.B.1.e.iii (inadequate response to test stimulation), removed I.B.3.d, and removed prior sphincteroplasty criteria I.B.2.

2025-05-25 (Approval Date noted as 05/25 in source)material_revision

Added criterion I.B.1.d (ability requirement) and removed I.B.1.e.iii (inadequate response to test stimulation) and I.B.3.d; sphincteroplasty criteria I.B.2 removed and CPT 44320 plus HCPCS C1767/C1778 added to coding tables.

2023-07-23