CurrenteoccoPolicy N/A

Treatment of Urinary and Fecal Incontinence

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Medical necessity and coverage criteria for procedures and devices used to treat urinary and fecal incontinence (including sacral nerve stimulation, posterior tibial nerve stimulation, artificial urinary sphincter, bulking agents, and other modalities) for members of the plan.

Policy Summary

Payereocco

PolicyTreatment of Urinary and Fecal Incontinence

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 1, 2026

Last ReviewMay 28, 2026

Next Review DateMay 28, 2026

Key ActionSubmit prior authorization with 12 months of treating physician chart notes documenting history, prior conservative therapy trials, and trial improvement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥ 12 monthsMinimum documented symptom duration for SNS/retention

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CurrenteoccoPolicy N/A

Treatment of Urinary and Fecal Incontinence

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Policy Summary

Payereocco

PolicyTreatment of Urinary and Fecal Incontinence

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 1, 2026

Last ReviewMay 28, 2026

Next Review DateMay 28, 2026

Key ActionSubmit prior authorization with 12 months of treating physician chart notes documenting history, prior conservative therapy trials, and trial improvement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥ 12 monthsMinimum documented symptom duration for SNS/retention

≥ 50%Trial improvement required for permanent SNS

12 treatmentsPTNS protocol

Codes listedCovered procedure codes

Codes listedNot covered codes

Coverage Criteria for Incontinence Treatments

SNS for urge urinary incontinence

Covered when ALL of the following are met:

SNS trial for urge urinary incontinence

Refractory to conventional therapy: Failure of a three-month trial of conventional therapy including: at least 2 different anticholinergic drugs OR 1 anticholinergic plus 1 beta-3 adrenergic agonist; AND behavioral treatments such as pelvic floor exercise, biofeedback, timed voids, or fluid management3 months trial

Permanent SNS implantation for urge urinary incontinence: All criteria for trial placement met AND a trial of the device has provided at least a 50% decrease in incontinence symptoms>=50% improvement

SNS for non-obstructive urinary retention

Covered when ALL of the following are met:

SNS trial for non-obstructive urinary retention: Documentation of 12 months of urinary retention with significant disability (symptoms limit participation in daily activities) AND conventional management has failed or is not tolerated/contraindicated, including appropriate pharmacotherapies (e.g., alpha blockers, cholinergics, antibiotics for UTIs) and intermittent catheterizationduration >= 12 months

Permanent SNS for non-obstructive urinary retention: Criteria for SNS trial met AND screening trial demonstrates a ≥ 50% decrease in residual urine volume documented by objective measurement comparing baseline to the trial period>=50% decrease in residual volume

Artificial urinary sphincter indications

Covered when one or more of the following are met:

Post-prostatectomy: Patient is 6 or more months post-prostatectomy with persistent urinary incontinence despite pharmacological therapy and behavior modification>=6 months post-op

Epispadias-exstrophy: Patient has epispadias-exstrophy and has not had success with bladder neck reconstruction surgery

Female intractable incontinence: Individual with female anatomy with intractable urinary incontinence who has failed behavioral modification, pharmacologic therapy, and other surgical treatments

Pediatric: Child with intractable urinary incontinence due to intrinsic urethral sphincter deficiency refractory to behavioral or pharmacologic therapy and unsuitable candidate for other surgical procedures

SNS for fecal incontinence

Covered when ALL of the following are met:

Indication: Treatment is for fecal incontinence and incontinent episodes average greater than 2 per week for 6 months or more>2 episodes/week for >=6 months

Not secondary to neurologic disease: Fecal incontinence is not secondary to neurologic disease (e.g., stroke, Parkinson's, multiple sclerosis) and there is absence of complete spinal cord impairment (e.g., transverse spinal cord injury)

Refractory to conventional therapy: Patient is refractory to pharmacotherapy and behavioral treatments such as dietary management, pelvic floor rehabilitation or strengthening exercises, biofeedback, timed voids

Permanent SNS for fecal incontinence: Screening trial demonstrates >= 50% improvement in incontinence symptoms over a trial period of at least 48 hours

Experimental / investigational treatments

Not covered / considered experimental or investigational for indicated uses:

Listed experimental therapies: Radiofrequency energy treatments (e.g., SURx, Renessa), Genityte (laser) procedures, pudendal nerve stimulation, autologous myoblast transplantation, autologous muscle-derived cell therapy, collagen porcine dermis mesh, stem cell therapy, ProACT system (extraurethral non-circumferential retropubic adjustable compression devices), radiofrequency micro-remodeling with SURs System, the Neocontrol (ExMI) system, and other treatments or systems not proven effective in evidence-based literature; bilateral sacral nerve stimulation for urinary incontinence is also considered experimental/investigational

CPT/HCPCS codes 53860 and E0740 are listed as not covered for these experimental indications

Specific procedures and systems are identified in the policy as experimental/investigational and not covered because effectiveness has not been established in evidence-based literature. Examples explicitly listed include radiofrequency energy treatments (e.g., SURx, Renessa), the Genityte laser procedure, pudendal nerve stimulation, autologous myoblast transplantation, autologous muscle-derived cell therapy, collagen porcine dermis mesh, stem cell therapies, the ProACT adjustable compression system, radiofrequency micro-remodeling with the SURs System, and the Neocontrol extracorporeal magnetic innervation (ExMI) system, among other unproven treatments.

The policy also names specific CPT/HCPCS codes that correspond to procedures or devices considered not covered: CPT 53860 (transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra) and HCPCS E0740 (incontinence treatment system, pelvic floor stimulator/monitor/sensor/trainer).

Sacral nerve stimulation (SNS) is considered experimental or investigational when the documented coverage criteria are not met. The policy specifies that SNS is not medically necessary if required elements—such as adequate diagnostic indication, minimum symptom duration, completion of conservative therapies, or an adequate screening trial—are lacking.

Examples of situations that render SNS investigational per the policy include: insufficient or absent trial improvement during the screening period, fecal incontinence that is secondary to neurologic disease or associated with complete spinal cord impairment, and indications outside those explicitly listed (for which effectiveness has not been established).

Coding and Diagnosis Codes

Covered CPT/HCPCS/CodesmixedCovered

64561	Percutaneous implantation of neurostimulator electrodes; sacral nerve.
64581	Implantation neurostimulator electrodes; sacral nerve.
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.
A4290	Sacral nerve stimulation test lead, each.
C1767	Generator, neurostimulator (implantable), non-rechargeable.
C1778	Lead, neurostimulator (implantable).
C1815	Prosthesis, urinary sphincter (implantable).
C1883	Adaptor/extension, pacing lead or neurostimulator lead (implantable).
C1897	Lead, neurostimulator test kit (implantable).

1–10 of 12

1/2

Not covered CPT/HCPCS CodesmixedNot Covered

53860	Transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence.
E0740	Incontinence treatment system, pelvic floor stimulator, monitor, sensor, and/or trainer.

Applicable ICD-10 diagnosis codesICD-10

F98.0	Enuresis not due to a substance or known physiological condition.
N30.10	Interstitial cystitis (chronic) without hematuria.
N30.11	Interstitial cystitis (chronic) with hematuria.
N31.2	Flaccid neuropathic bladder, not elsewhere classified.
N31.8	Other neuromuscular dysfunction of bladder.
N31.9	Neuromuscular dysfunction of bladder, unspecified.
N32.81	Overactive bladder.
N36.44	Muscular disorders of urethra.
N39.3	Stress incontinence (female) (male).
N39.41	Urge incontinence.

1–10 of 21

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SNS trial improvement threshold

SNS trial improvement threshold≥ 50% decrease in incontinence symptoms (trial) or ≥ 50% decrease in residual urine volume (for retention) compared with baseline

Measurement basisImprovement documented by symptom decrease for urge incontinence or objective residual urine volume measurement for retention

Applicable to permanent implantationPermanent SNS implantation requires meeting the ≥50% improvement threshold after an adequate screening/trial period

Fecal incontinence episode threshold

Fecal incontinence episode thresholdIncontinent episodes average greater than 2 per week for 6 months or more

Duration requirement

Provider Requirements and Prior Authorization

Prior Authorization

Prior authorization: submit chart notes and 12 months of SNS documentation

Prior authorization is required for sacral nerve stimulator procedures. Submit the treating physician's chart notes documenting history of incontinence and prior treatments; for SNS review include 12 months of treating physician chart notes showing the documented criteria are met. Include relevant CPT/HCPCS codes for the planned procedure.

Treating physician chart notes documenting history and treatments
12 months of treating physician chart notes for SNS review
Relevant CPT/HCPCS codes (see coding section)

Step Therapy

Document prior conservative therapies (behavioral + pharmacologic) before SNS

Document that the patient has failed conservative management before SNS trial: a three-month trial including behavioral therapies and pharmacologic therapy. Pharmacologic failure must include either at least two different anticholinergic drugs OR one anticholinergic plus one beta-3 adrenergic agonist; behavioral treatments must include measures such as pelvic floor exercise, biofeedback, timed voids, or fluid management.

Definitions

Sacral Nerve Stimulation (SNS / InterStim)

DefinitionImplantation of electrical leads contacting sacral nerve roots connected to a subcutaneous pulse generator to deliver controlled electrical impulses to modulate sacral nerve activity for urge urinary incontinence, urgency/frequency, and some cases of fecal incontinence

ComponentsLead(s) placed near the sacral nerve root and a subcutaneously implanted pulse generator that is programmed by the physician; patient can switch the device on/off

Indications referencedUsed for treatment of urge urinary incontinence, symptoms of urge frequency, non-obstructive urinary retention (with objective response), and chronic fecal incontinence when criteria are met

Posterior Tibial Nerve Stimulation (PTNS)

DefinitionMinimally invasive percutaneous stimulation of the posterior tibial nerve via a fine needle electrode connected to a pulse generator to deliver retrograde stimulation to the sacral plexus

Background and Clinical Context

Management options for urinary and fecal incontinence encompass conservative behavioral therapies, pharmacologic treatments, rehabilitative approaches, and procedural or device-based interventions. Behavioral and rehabilitative measures commonly include pelvic floor muscle training, biofeedback, timed voiding, and dietary management; pharmacotherapies include anticholinergic agents, beta-3 adrenergic agonists, alpha blockers and cholinergic agents depending on the indication.

Neuromodulation is an established option for select patients: sacral nerve stimulation (SNS) involves implantation of leads contacting sacral nerve roots and a pulse generator to modulate bladder or bowel function and may be used for urge urinary incontinence, non‑obstructive urinary retention, and chronic fecal incontinence when specific criteria are met (including minimum symptom duration and response thresholds during a screening trial). Posterior tibial nerve stimulation (PTNS) is a less invasive neuromodulation approach delivered percutaneously, typically in a 12‑treatment protocol.

Surgical devices such as the artificial urinary sphincter are indicated in defined circumstances (for example, persistent post‑prostatectomy incontinence ≥ 6 months post‑op, failure of conservative and pharmacologic therapies, or selected congenital conditions). The policy notes that many newer or alternative interventions (e.g., various energy‑based systems, pudendal nerve stimulation, cell therapies, and other listed devices) are considered experimental and are not covered pending established effectiveness.

Policy Revision History

2002-07origin

Policy originated (Date of Origin: 07/2002).

2013-02revision

Annual review with addition of PTNS criteria and set effective date 2013-03-01.

2014-02annual_review

Annual review performed; no content changes and effective date updated to 2014-02-25.

Policy Summary

Payereocco

PolicyTreatment of Urinary and Fecal Incontinence

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 1, 2026

Last ReviewMay 28, 2026

Next Review DateMay 28, 2026

Key ActionSubmit prior authorization with 12 months of treating physician chart notes documenting history, prior conservative therapy trials, and trial improvement.

SourceLink

On This Page

Minimum trial period 48 hours for screening trial

Episodes must persist for at least 6 months to meet criteria

Exclusion for neurologic causesFecal incontinence must not be secondary to neurologic disease (e.g., stroke, Parkinson's, multiple sclerosis) and there must be absence of complete spinal cord impairment

At least 2 different anticholinergic drugs OR 1 anticholinergic + 1 beta-3 agonist
Behavioral treatments (pelvic floor exercise, biofeedback, timed voids, fluid management)
Three-month trial of conventional therapy documented

Documentation Required

Required documentation: physician chart notes, history, treatment trials, and 12 months for SNS

Include treating physician chart notes that document the history of incontinence, specific treatments tried, duration of symptoms, and objective trial results; for sacral nerve stimulators provide 12 months of chart notes showing criteria are met with documentation of prior therapies and trial outcomes.

History of incontinence and its impact (12 months duration when required)
Details of behavioral and pharmacologic treatment trials (dates, agents, durations)
Objective measurement of trial improvement (e.g., % decrease in symptoms or residual urine volume)

Denial Risk

Denial triggers: missing duration, missing therapies, or insufficient trial improvement (<50%)

Claims may be denied if required criteria are not documented: missing required symptom duration, absent or incomplete prior conservative therapy documentation, or if the SNS trial did not demonstrate the required improvement (less than 50%).

Missing documentation of 12 months of symptoms when required
No record of the required three-month conventional therapy trial (pharmacologic + behavioral)
SNS screening or trial improvement under the required threshold (<50% improvement or <50% decrease in residual volume)

Typical protocolTreatment protocol is 12 treatments, once weekly (commonly performed with devices such as Urgent® PC)

IndicationsIndicated for urinary urgency, urinary frequency, and urge incontinence

Artificial Urinary Sphincter

Device descriptionInflatable cuff placed around the urethra with an associated balloon reservoir and control pump to regulate cuff inflation and deflation

Implantation summarySurgically implanted cuff around the urethra with balloon placed (e.g., in the abdomen) and control pump typically placed in the scrotum for men or labia for women; cuff inflated to prevent incontinence and deflated to permit voiding

Typical use casesUsed for post-prostatectomy incontinence, congenital abnormalities (e.g., epispadias-exstrophy), refractory female incontinence, and select pediatric cases when conservative therapies have failed

2015-09revision

Annual review added ICD-9, ICD-10, HCPC, CPT, and Medicare references (effective 09/2015).

2016-03revision

Annual review updated CPT/HCPC references and template; effective date updated to 03/23/2016.

2017-07-01revision

Annual review updated template and clarified PTNS clinical requirements (effective 07/01/2017).

2018-08-22revision

Annual review clarified posterior tibial nerve stimulation and updated HCPC codes (effective 08/22/2018).

2020-10update

Updated HCPC code L8695 added (effective 10/2020).

2021-03annual_review

Annual review; deleted termed code L8604 with no clinical content change (effective 04/01/2021).

2022-03annual_review

Annual review performed with no changes (effective 04/01/2022).

2023-05annual_review

Annual review with grammar updates (effective 06/01/2023).

2024-05annual_review

Annual review with grammar updates (effective 06/01/2024).

2025-05revision

Annual review added requirements for treating fecal incontinence and updated CPT codes (effective 06/01/2025).

2026-05-28last_reviewLatest

Most recent review completed (Last Review Date: 05/28/2026).

2026-06-01effective_date

Current policy effective date (Effective Date: 06/01/2026).