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.

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.

• Codes that do NOT support coverage criteria include CPT 46760, 46761, 64581, 64590 and HCPCS L8683.
• Use the CPT and HCPCS codes listed in the policy’s coding sections (CPT codes such as 44320, 46750, 46751, 46999, 64561, 64585, 64595, 95970–95971; HCPCS codes such as A4290, A4335, C1767, C1778, L8680–L8682, L8684–L8689, etc.) when they apply.

Required Clinical Documentation

Provide complete clinical documentation demonstrating the medical necessity criteria are met. Documentation must show severity, duration, prior therapies tried, and treatment response.

• Document severe, chronic fecal incontinence defined as >2 incontinent episodes per week on average and duration >6 months.
• Document that conservative therapies (e.g., pharmacotherapy, dietary management, strengthening exercises) were attempted and did not produce adequate response.
• For sacral neuromodulation, include results of percutaneous test stimulation showing ≥50% sustained symptom improvement for more than one week.
• Document that the member previously achieved bowel control and can operate the device or has an appropriate caregiver to assist.

Documentation and Applicability Reminders

This policy is a medical necessity guideline and does not guarantee coverage or payment. Providers should align requests with applicable state and federal rules and the member’s benefit contract.

• Clinical policy guides medical necessity determinations but coverage is subject to the member’s benefit plan, contract terms, exclusions and applicable laws.
• Retain and submit supporting records (clinic notes, bowel diaries, prior treatments, test stimulation reports, device operation training) with the authorization request.

Conservative Therapy Prerequisite

Prior to requesting advanced interventions, conservative management must have been tried and failed. Authorization requests should document the nature and duration of conservative therapies.

• Conservative therapies include pharmacologic treatment, dietary modification, pelvic floor strengthening/exercises, and correction of anatomic defects when applicable.
• State the duration and outcomes of conservative therapy and why further conservative care is not appropriate or effective.

Follow Referenced Step Therapy Guidance

Follow referenced step-therapy guidance and specialty guidelines when applicable. Requests should reference relevant guideline recommendations and local coverage determinations used to support the treatment plan.

• Cite applicable clinical guidance (e.g., ACOG, ACG, UpToDate) or local coverage determinations when supporting the treatment sequence.
• When a staged approach is recommended (e.g., conservative care → test stimulation → implant), submit documentation for each completed stage.