CurrentColorado Rocky Mountain Health PlansPolicy CS358.E

Sacral Nerve Stimulation for Urinary and Fecal Indications

Clinical coverage policy for sacral nerve stimulation (also called sacral neuromodulation) in adults (≥18 years) for urinary voiding dysfunction and fecal incontinence; includes criteria for screening trial, permanent implantation, revisions/replacements, and exclusions (constipation, chronic pelvic pain).

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicySacral Nerve Stimulation for Urinary and Fecal Indications

Policy CodePolicy CS358.E

Change TypeTerminology and template updates

Effective DateDec 1, 2025

Next Review Date

Key ActionDocument prior conservative therapies and objective trial-phase improvement (≥50%) and include supporting records for prior authorization and medical necessity determinations.

SourceLink

POLICY UPDATE CHANGES

Template update removed content/language pertaining to the state of Louisiana and updated a related policy link.

Coverage rationale language replaced references to 'Sacral Nerve Stimulation' with 'Sacral Nerve Stimulation (neurostimulation)'; definition of SNS/SNM added; supporting information updated.

≥18Age applicability

50%Threshold for successful screening trial

≥300 mLChronic urinary retention definition (PVR)

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Medical Necessity Criteria for Sacral Nerve Stimulation (SNS)

Medically Necessary 2D SNS screening trial for urinary voiding dysfunction

Screening trial is medically necessary when ALL of the following are met:

Medically Necessary 2D SNS permanent implantation for urinary voiding dysfunction

Permanent implantation is medically necessary when ALL of the following are met:

ALL of the following

All criteria for SNS screening trial have been met
Improvement in reported symptoms of 50% or greater in response to a screening trial of SNS

Medically Necessary 2D SNS screening trial for fecal incontinence

Screening trial is medically necessary when ALL of the following are met:

ALL of the following

Symptoms refractory to conservative care (e.g., bowel training, bulking agents, pelvic floor rehabilitation, pharmacological therapy)
Individual capable of operating sacral nerve stimulating device
Fecal incontinence is not secondary to a neurologic disease origin (e.g., Parkinson's disease, stroke, spinal cord injury, multiple sclerosis)
Fecal incontinence is not secondary to constipation
Lack of distorted anatomy (e.g., anorectal malformation, abscess or fistula, rectal surgery)

Medically Necessary 2D SNS permanent implantation for fecal incontinence

Permanent implantation is medically necessary when ALL of the following are met:

ALL of the following

All criteria for SNS screening trial for fecal incontinence have been met
Improvement in reported symptoms of 50% or greater in response to a screening trial of SNS

Revisions / replacements

Device replacement or revision is medically necessary when ALL of the following are met:

ALL of the following

Individual has met all applicable above criteria (original indication and prior success criteria)
Existing device is nonfunctional and either cannot be repaired or is no longer under warranty

Not medically necessary / Unproven

SNS is considered not medically necessary for the following indications due to insufficient evidence:

ANY of the following

Constipation
Chronic pelvic pain

Test-phase success / criteria for permanent SNM implantation

Guideline-based criteria for proceeding from test stimulation (PNE or Stage 1) to full implant:

ALL of the following

Patient achieves >= 50% improvement in one or more troublesome urinary or bowel parameters during the PNE or Stage 1 test period
This is the commonly cited threshold across ICS/EAU/AGA/AUA guidance.
Test types and typical durations
- Percutaneous nerve evaluation (PNE): typically 7 days for bladder indications and 10-21 days for bowel indications
- Stage 1 (temporary lead) testing: typically 2-3 weeks; used when longer testing is needed or PNE is questionable

Absolute contraindications

Per ICS expert panel:

ANY of the following

Insufficient clinical response to a therapeutic trial
Incapability to operate the device with absence of supportive caregivers
Pregnancy

Relative contraindications

Per ICS expert panel:

ANY of the following

Severe or rapidly progressive neurologic disease
Established complete spinal cord injury (SCI)
Known expected need for MRI of body parts below the head (device incompatibility considerations)
Abnormal sacral anatomy

Indications supported by guideline syntheses and evidence summaries

Guidelines and systematic reviews summarized support or do not support SNM for the following conditions:

Evidence-level and limitations summary (synthesized)

Common methodological themes affecting interpretation of SNM literature:

ALL of the following

Many studies are case series, before-and-after studies, or small RCTs with risk of bias and heterogeneity
Comparative randomized data are limited or show conflicting results for some indications (eg, constipation)
Long-term device-related adverse events, revision and explantation rates are non-trivial (revision rates often 30%+ over years; systematic review reports 35.2% revisions for FI)
Test-phase response is the best predictor of longer-term success; trial stimulation remains central to patient selection

Contraindications for Sacral Neuromodulation (SNM)

Absolute and relative contraindications described:

Preoperative counseling and assessment

Providers should perform preoperative counseling and evaluate specific items before SNM:

ALL of the following

Discuss SNM therapy as part of bowel or bladder control treatment pathway
Evaluate necessity for lifelong follow-up, future battery replacement, complications, and anticipated symptom improvement
Provide preoperative counseling on risks including implant site pain, infection, paresthesia, leg pain, need for reprogramming or device revision

Screening and testing period success criteria

Criteria to consider offering full implantation after test stimulation:

ALL of the following

Patient achieves 50% improvement in one or more troublesome urinary or bowel parameters during PNE or Stage 1 test period
Typical test durations
- PNE test stimulation period: typically 7 days for bladder
- PNE test stimulation period: typically 10-21 days for bowel indications
- Stage 1 test period: typically 2-3 weeks
Consider both sensory and motor responses important for predicting success

Definition of successful outcome

How success is judged for bladder and bowel indications:

ANY of the following

An individual satisfied with the treatment is considered to have a successful treatment outcome
For voiding dysfunction or neurogenic lower urinary tract dysfunction (nLUTD), further evaluations may be necessary to ensure long-term urologic tract safety

Relevant Procedure, Device, and Diagnosis Codes

CPT / HCPCS procedure codes (reference)mixed

0784T	Insertion or replacement of percutaneous electrode array, spinal, with integrated neurostimulator, including imaging guidance, when performed
0785T	Revision or removal of neurostimulator electrode array, spinal, with integrated neurostimulator
0786T	Insertion or replacement of percutaneous electrode array, sacral, with integrated neurostimulator, including imaging guidance, when performed
0787T	Revision or removal of neurostimulator electrode array, sacral, with integrated neurostimulator
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
64595	Revision or removal of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, with detachable connection to electrode array

HCPCS L-codes (implantable device supplies)HCPCS

L8679	Implantable neurostimulator, pulse generator, any type
L8680	Implantable neurostimulator electrode, each
L8682	Implantable neurostimulator radiofrequency receiver
L8685	Implantable neurostimulator pulse generator, single array, rechargeable, includes extension
L8686	Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension
L8687	Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension
L8688	Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension

ICD-10 diagnosis codes — Urinary indicationsICD-10

N32.81	Overactive bladder
N32.9	Bladder disorder, unspecified
N39.3	Stress incontinence
N39.41	Urge incontinence
N39.42	Incontinence without sensory awareness
N39.46	Mixed incontinence
N39.490	Overflow incontinence
N39.498	Other specified urinary incontinence
R30.0	Dysuria
R30.1	Vesical tenesmus

1–10 of 31

1/4

ICD-10 diagnosis codes — Fecal indicationsICD-10

R15.0	Incomplete defecation
R15.1	Fecal smearing
R15.2	Fecal urgency
R15.9	Full incontinence of feces

Documentation, Authorization, and Denial Risks

Prior Authorization

Prior authorization likely required for implant and revisions

Policy language will be used to determine medical necessity for implantation and revisions; obtain and be prepared to submit medical records that document how the case meets the policy criteria for pre-authorization and review.

Documentation Required

Document prior conservative therapies and refractoriness

Document prior conservative therapies and that symptoms were refractory before trialing SNS. Include records of bladder or bowel training, pelvic floor rehabilitation, pharmacologic therapy, and use of bulking agents where applicable.

Bladder/bowel training
Pelvic floor rehabilitation
Pharmacologic therapy
Bulking agents (for bowel indications)

Key Clinical Thresholds and Test Durations

Key thresholds and test durations

Successful screening trial response≥ 50% improvement in reported symptoms

Bladder capacity≥ 100 mL

Chronic urinary retention definitionPostvoid residual (PVR) ≥ 300 mL persisting ≥ 6 months documented on ≥ 2 occasions

PNE test duration (bladder)7 days (typical)

PNE test duration (bowel)10–21 days (typical)

Stage 1 test duration2–3 weeks (typical)

50%

Clinical and Evidence Context

Sacral nerve stimulation places a small electrode tip near the sacral nerve (commonly the S3 foramen) to modulate afferent signaling and alter bladder and bowel function; the implanted neurostimulator delivers ongoing stimulation akin to a pacemaker for pelvic organ control. A short screening trial is performed first — typically a percutaneous nerve evaluation (PNE) lasting about 3–7 days for bladder indications (with longer PNE durations described for bowel indications) or a temporary lead (Stage 1) test lasting 2–3 weeks when longer assessment is needed. Successful screening trials are commonly defined as patient-reported or objective symptom improvement of at least 50%, and individuals with a successful trial may proceed to permanent implantation of an implantable pulse generator and lead system. SNS/SNM is an established therapy for overactive bladder (OAB) including urgency urinary incontinence (UUI), nonobstructive urinary retention (NOUR), and for fecal incontinence (FI) when specified criteria are met (including prior conservative therapy failure and exclusion of secondary causes).

Guidelines and evidence syntheses generally support use of SNM for refractory fecal incontinence and refractory overactive bladder/UUI and recognize SNM as an option for NOUR and selected underactive bladder cases; major specialty guidance (ICS, AUA/SUFU, EAU, ACG/AGA/ASCRS) endorse a test-phase before permanent implantation and use a common success threshold of ≥50% improvement in one or more troublesome urinary or bowel parameters to proceed. However, evidence quality and study designs vary: much of the literature comprises case series, before-and-after studies, and small RCTs with heterogeneity and risk of bias, limiting strength of inference for some indications such as constipation and chronic pelvic pain. Long-term device-related event rates are notable — systematic reviews report substantial revision and explantation rates (for example, an aggregate revision rate of 35.2% and explantation rate of 19.7% in a long-term FI review), and guideline panels cite surgical revision rates commonly in the 30–40% range at 3–4 years — all of which should be considered during patient selection and counseling. Finally, the trial stimulation response remains the best predictor of longer-term benefit, and limitations in comparative randomized data (and mixed results for indications like constipation and some neurogenic conditions) mean careful, guideline-informed selection and follow-up are required.

Defined Terms

Definitions

CPPPersistent or recurrent episodic pelvic pain associated with urinary, sexual, bowel, or gynecologic dysfunction without proven infection or other obvious pathology.

Chronic Urinary RetentionPostvoid residual volume (PVR) ≥ 300 mL that persists for ≥ 6 months and is documented on ≥ 2 separate occasions.

ConstipationSyndrome defined by difficult or infrequent passage of stool, hard stool, or a feeling of incomplete evacuation.

Fecal Incontinence (FI)Involuntary passage of fecal matter or inability to control discharge of bowel contents; severity ranges from flatus to complete evacuation.

Fowler's SyndromeCondition with large bladder capacity, reduced sensation, increased urethral closure pressure, and detrusor underactivity, often in young post-menarche women associated with prior trigger events.

PNEPercutaneous nerve evaluation — a short-duration trial stimulation (typically 7 days bladder, 10–21 days bowel) to assess response before permanent implantation.

Policy Updates

2026-04-01Template update / editorialLatest

Template update removed content/language pertaining to the state of Louisiana and updated a related policy link.

2025-12-01Coverage rationale and supporting information update

Coverage rationale language standardized to 'Sacral Nerve Stimulation (neurostimulation)', definition of SNS/SNM added, clinical evidence, FDA, and references updated, and previous policy version CS358.D archived.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicySacral Nerve Stimulation for Urinary and Fecal Indications

Policy CodePolicy CS358.E

Change TypeTerminology and template updates

Effective DateDec 1, 2025

Next Review Date

Key ActionDocument prior conservative therapies and objective trial-phase improvement (≥50%) and include supporting records for prior authorization and medical necessity determinations.

SourceLink

On This Page

Documentation Required

Document exclusionary secondary causes

Document that the presenting urinary or fecal dysfunction is not secondary to excluded causes: not due to neurologic disease, not from urinary outlet or mechanical obstruction (for urinary indications), not secondary to constipation (for fecal indications), and absence of distorted anorectal anatomy for bowel cases.

Not secondary to neurologic disease (eg, Parkinson's, stroke, spinal cord injury, MS)
No bladder outlet or mechanical obstruction (eg, BPH, tumor/radiation, urethral stricture)
Fecal incontinence not secondary to constipation
No distorted anatomy (eg, anorectal malformation, abscess/fistula, prior rectal surgery)

Documentation Required

Record trial outcome

Record objective and/or patient‑reported screening trial results showing the degree of symptom improvement; permanent implantation requires documentation of a ≥50% improvement in reported symptoms during the screening trial.

Document symptom scores, voiding/bowel diaries, or other measures showing ≥50% improvement

Documentation Required

Document test-phase response

For the test phase, document test type (PNE or Stage 1), test duration, and measured improvement; test documentation must show the degree of symptom change (≥50% improvement is the guideline threshold).

Specify PNE vs Stage 1 (typical PNE: 7 days bladder, 10–21 days bowel; Stage 1: 2–3 weeks)
Quantify improvement (eg, percent improvement in target symptoms)

Prior Authorization

Therapeutic trial requirement prior to permanent implantation

An adequate therapeutic trial (PNE or Stage 1) demonstrating ≥50% improvement is required before offering permanent implantation; document the trial type, duration, and the ≥50% response to justify proceeding to a full system implant.

PNE or Stage 1 trial must be documented
Recorded improvement ≥50% in one or more troublesome parameters

Denial Risk

Risk of denial for excluded indications

Requests for SNS for constipation or chronic pelvic pain are considered unproven and not medically necessary; such requests are subject to denial under this policy.

Constipation (slow transit or refractory) is listed as not medically necessary/insufficient evidence
Chronic pelvic pain is listed as not medically necessary/insufficient evidence

Prior Authorization

Pre-implant counseling and follow-up planning

Provide pre‑implant counseling that documents life‑long follow‑up needs, likely future battery replacement, potential complications (infection, pain, lead migration, need for reprogramming or revision), and the probability of revision or explantation; document patient ability to operate the device or presence of caregiver support.

Lifelong follow-up and future battery replacement
Risks: implant site pain, infection, paresthesia, leg pain, need for reprogramming or device revision
Document patient capability to operate device or caregiver support

Documentation Required

Pre-procedure diagnostic assessments for bowel indications

For bowel indications, obtain a 2–3 week bowel diary prior to testing and consider anorectal physiology testing (manometry, sensation, volume tolerance) to characterize dysfunction and guide management; document these assessments in the record.

2–3 week bowel diary before SNM test
Consider anorectal manometry, anorectal sensation testing, and maximum tolerated volume assessments

Denial Risk

Contraindication-related denial risk

Do not proceed with implantation if any absolute contraindication is present (insufficient trial response, inability to operate device without caregivers, pregnancy). If relative contraindications exist (eg, severe progressive neurologic disease, complete SCI, need for MRI below the head, abnormal sacral anatomy), document careful consideration and rationale.

Absolute contraindications require withholding implantation
Relative contraindications need documented justification and caution

Documentation Required

Preoperative counseling and informed consent

Document preoperative counseling and informed consent addressing the long‑term commitment, risks, need for test stimulation, likelihood of test success, potential need for revisions or removal, and the follow‑up/self‑referral plan if symptoms recur.

Counsel regarding test stimulation and probability of success
Discuss risks, need for revisions or device removal, and long‑term commitment
Provide plan for follow-up and how to self‑refer if symptoms recur

Sacral Nerve Stimulation for Urinary and Fecal Indications

Medical Necessity Criteria for Sacral Nerve Stimulation (SNS)

Relevant Procedure, Device, and Diagnosis Codes

Documentation, Authorization, and Denial Risks

Key Clinical Thresholds and Test Durations

Clinical and Evidence Context

Defined Terms

Policies to Review Alongside This Policy

Policy Updates