CurrentCignaPolicy Medical Coverage Policy: 0404

Sacral Nerve Stimulation for Urinary Voiding Dysfunction, Fecal Incontinence and Constipation

Defines Cigna coverage policy for permanent sacral nerve stimulation (SNS) implantation and implantable tibial nerve stimulation for urinary voiding dysfunction and fecal incontinence, and states SNS is not medically necessary for constipation or other indications. Includes coding guidance and Medicare determinations.

Policy Summary

PayerCigna

PolicySacral Nerve Stimulation for Urinary Voiding Dysfunction, Fecal Incontinence and Constipation

Policy CodePolicy Medical Coverage Policy: 0404

Change TypeFocused & Annual Reviews (removals and title change)

Effective DateNov 15, 2025

Next Review Date

Key ActionProvider must document that a screening trial produced at least a 50% improvement in reported symptoms prior to permanent SNS implantation.

SourceLink

POLICY UPDATE CHANGES

Removed policy statement for screening trial of sacral nerve stimulation (SNS) for Urinary Voiding Dysfunction.

Removed policy statement for screening trial of sacral nerve stimulation for Fecal Incontinence.

Removed policy statement for Implantable Tibial Nerve Stimulation.

Title change.

Removed policy statement for percutaneous tibial nerve stimulation (PTNS) maintenance therapy and number of treatments allowed.

2Covered Indications (urinary voiding dysfunction, fecal incontinence)

1Not covered Indications (constipation)

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Coverage Summary

Scope: Defines Cigna coverage policy for permanent sacral nerve stimulation (SNS) implantation and implantable tibial nerve stimulation for treatment of urinary voiding dysfunction and fecal incontinence, and states SNS is not medically necessary for constipation and other non-covered indications.

Subject: Sacral Nerve Stimulation (SNS) for urinary voiding dysfunction and fecal incontinence.

Status: CURRENT.

Policy number: Medical Coverage Policy: 0404.

Effective date: 2025-11-15; Last review date: 2025-10-15.

Key policy facts

PolicyMedical Coverage Policy: 0404

PayerCigna

SubjectSacral Nerve Stimulation (SNS) for urinary voiding dysfunction and fecal incontinence

StatusCURRENT

Effective Date2025-11-15

Last Review2025-10-15

Scope summaryDefines Cigna coverage policy for permanent sacral nerve stimulation (SNS) implantation and implantable tibial nerve stimulation for urinary voiding dysfunction and fecal incontinence; states SNS is not medically necessary for constipation or other indications; includes coding guidance and Medicare determinations.

Medical Necessity Criteria

Urinary Voiding Dysfunction - Medically Necessary Permanent SNS

Permanent sacral nerve stimulation (SNS) implantation is considered medically necessary when ALL of the following are met:

Indication is urinary voiding dysfunction (urinary urge incontinence, nonobstructive urinary retention, or overactive bladder symptoms including urinary frequency and/or urgency, with or without incontinence)
See definition of urinary voiding dysfunction
Screening Trial Response
- Response Threshold: Beneficial response evidenced by at least a 50% improvement in reported symptoms (e.g., urinary urgency, frequency, nocturia, incontinence)>= 50%
  Required to proceed to permanent implantation

Metadata

Provider Actions & Billing Impact

Documentation Required

Document beneficial response to SNS screening trial

Provider must document that a screening trial (external PNE or two-stage implant trial) produced at least a 50% improvement in reported symptoms prior to permanent SNS implantation.

Billing Rule

Use appropriate codes for SNS procedures and devices

Claims must be billed with the most appropriate procedure and device codes. Services billed for diagnoses not covered under this policy will be denied.

64590
C1767
C1778
C1787

Procedure & Device Codes

Covered procedure codeCPTCovered

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

Covered HCPCS / Implantable device codesHCPCSCovered

C1767	Generator, neurostimulator (implantable), non-rechargeable
C1778	Lead, neurostimulator (implantable)
C1787	Patient programmer, neurostimulator
C1820	Generator, neurostimulator (implantable), with rechargeable battery and charging system
C1883	Adaptor/extension, pacing lead or neurostimulator lead (implantable)

Covered L-codes for neurostimulator componentsHCPCSCovered

L8679	Implantable neurostimulator, pulse generator, any type
L8680	Implantable neurostimulator electrode, each
L8681	Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only
L8682	Implantable neurostimulator radiofrequency receiver
L8685	Implantable neurostimulator pulse generator, single array, rechargeable, includes extension
L8686	Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension
L8687	Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension
L8688	Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension

Background & Definitions

Background: Sacral nerve stimulation (SNS) is a programmable surgically implanted neurostimulator proposed for use after failure, intolerance, or contraindication to conservative management to modulate sacral nerve signaling and improve urinary and fecal symptoms; prior to permanent implantation a screening trial is performed using external percutaneous nerve evaluation (PNE) or a two-stage implant trial.

Screening trial and purpose: The screening trial (external PNE or two-stage implant) assesses whether patients have a beneficial clinical response to SNS; the policy requires demonstration of at least a 50% improvement in reported symptoms during the trial to proceed to permanent implantation.

Evidence summary: Randomized clinical trials, prospective case series, retrospective analyses, and systematic reviews support the safety and effectiveness of SNS for select patients with urinary voiding dysfunction; evidence for fecal incontinence includes prospective and retrospective studies, systematic reviews and meta-analyses though high-quality RCT data is limited. Evidence is insufficient to support SNS for constipation.

Regulatory notes: The InterStim and Axonics sacral neuromodulation systems have received FDA Premarket Approval (PMA) for urinary and fecal indications.

Term	Definition
Urinary voiding dysfunction
Includes urinary urge incontinence, nonobstructive urinary retention, and overactive bladder symptoms (frequency, urgency, nocturia) with or without incontinence.
Fecal incontinence
Involuntary leakage of fecal matter through the anus or inability to control discharge of bowel contents.
Screening trial
Temporary external SNS (PNE) or two-stage implant procedure used to assess response prior to permanent implantation.

Thresholds

Screening trial response threshold>= 50% improvement in reported symptoms

Medicare Determinations

Type	Name	Number	Effective Date
NCD
Sacral Nerve Stimulation For Urinary Incontinence
230.18
2002-01-01
LCD
Sacral Nerve Stimulation for the Treatment of Urinary and Fecal Incontinence
L39543
2023-11-05

Revision History

2025-11-15removedLatest

Focused Review removed the screening trial policy statement for sacral nerve stimulation (SNS) for Urinary Voiding Dysfunction.

2025-11-15removedLatest

Focused Review removed the screening trial policy statement for sacral nerve stimulation (SNS) for Fecal Incontinence.

2025-10-15