CurrentHealth NetPolicy CP.MP.137

Clinical Policy: Fecal Incontinence Treatments

Clinical policy governing medical necessity and coverage guidance for procedures and devices used to treat fecal incontinence for Health Net members; intended for providers submitting claims and prior authorization requests.

Policy Summary

PayerHealth Net

PolicyClinical Policy: Fecal Incontinence Treatments

Policy CodePolicy CP.MP.137

Change TypeRevised criteria and coding additions

Effective Date

Next Review Date

Key ActionWhen submitting prior authorization or claims, include documentation showing the member previously achieved bowel control and evidence addressing the new I.B.1.d functional ability requirement.

SourceLink

POLICY UPDATE CHANGES

Removed '≥ 4 years age' criteria and added '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. requiring that the member/enrollee demonstrates the ability (functional requirement) and removed several prior specific criteria (I.B.1.e.iii and I.B.3.d).

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

Added HCPCS code L8683 description update and updated CPT descriptions for 46760, 46761, 64581, 64590.

Background and description verbiage updated with minor rewording with no impact on criteria; references reviewed and updated.

multiplereferences updated/ reviewed

3+added/removed criteria items

3new codes added

severalannual reviews noted

Coverage Criteria and Policy Rules

Revised coverage criteria (sections I.A and I.B)

Covered when ALL of the following revised criteria in sections I.A and I.B are met:

I.A (revised): Member/enrollee has previously achieved bowel control (replaces prior minimum age '≥ 4 years'); definition of severe, chronic fecal incontinence no longer limited by 'more than twelve months after vaginal childbirth'.

Full decision nodes for I.A are detailed in the policy; this node reflects the operational revisions to I.A.

I.B (revised): Procedures subject to I.B require meeting the updated pre-procedure requirements, including the newly added functional ability requirement I.B.1.d and removal of certain former prerequisites (I.B.1.e.iii regarding inadequate response to test stimulation; I.B.3.d regarding absence of any physical or mental illness). Previous I.B.2 for sphincteroplasty was removed.

Exact wording of I.B.1.d is in the full policy text; include documentation demonstrating the member meets the functional ability requirement.

The policy identifies a set of HCPCS/CPT codes that do not support coverage criteria for the procedures and devices addressed in this document. The source document explicitly lists these coding notes and states that updated descriptions were applied to CPT codes 46760, 46761, 64581, 64590 and HCPCS code L8683. These coding entries are informational for billing and coding purposes and indicate those specific codes are not tied to the policy’s coverage decision logic.

Policy Summary

PayerHealth Net

PolicyClinical Policy: Fecal Incontinence Treatments

Policy CodePolicy CP.MP.137

Change TypeRevised criteria and coding additions

Effective Date

Next Review Date

SourceLink

On This Page

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No standalone "not medically necessary" (NMN) statements are provided in the extracted window for the HCPCS codes; instead the document notes that certain HCPCS/CPT codes do not support coverage criteria. Providers should refer to the coding tables and updated descriptions in the policy for exact coding guidance. When submitting claims or prior authorization requests, include documentation that matches the revised criteria rather than relying on separate NMN wording for these codes.

Coding and Procedure Codes

HCPCS codes that do not support coverage criteria / updated CPT/HCPCS descriptionsmixed

46760	CPT code description updated in document
46761	CPT code description updated in document
64581	CPT code description updated in document
64590	CPT code description updated in document
L8683	HCPCS code description updated in document

Newly added codesmixed

44320	CPT code added to coding tables
C1767	HCPCS code added to coding tables
C1778	HCPCS code added to coding tables

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for procedures and products when applicable. Note that CPT 44320 and HCPCS C1767 and C1778 have been added to the coding tables and may require prior authorization and supporting documentation per Health Net policy.

Affected codes: CPT 44320; HCPCS C1767, C1778

Documentation Required

Provider Actions — Documentation Required

Providers must submit complete documentation showing that the member previously achieved bowel control and meets the revised clinical criteria (see I.A/I.B). Failure to provide the required evidence elements may delay review or lead to denial.

Required evidence: prior achievement of bowel control; demonstration of functional ability per I.B.1.d; any other supporting clinical notes or test results referenced in criteria

Denial Risk

Denial Risk from Missing Criteria

If the updated I.A/I.B criteria are not met or documentation is incomplete (for example: no evidence of prior bowel control, missing demonstration of functional ability, or omitted timeframes), the request is at increased risk for denial. Review criteria carefully before submission.

Denial risk factors: absence of documented prior bowel control; missing I.B.1.d evidence; omission of required test or clinical notes

Note

Provider Actions — Coding and Submission

Action: Verify coding on claims and authorization requests to include newly added codes and provide supporting documentation mapped to each code/procedure. Ensure prior authorization is requested when billing CPT 44320 or HCPCS C1767/C1778 and include the clinical evidence elements required by the revised criteria.

For CPT 44320, HCPCS C1767, C1778 — include clinical rationale and documentation of prior bowel control and functional assessments
Confirm prior authorization status before performing or billing these services

Background and Rationale

Background language in this policy was updated with minor rewording and reviewed references; these edits were described as having no clinical significance. The revision history documents multiple annual reviews and notes that the policy references clinical guidance and literature, with external specialist review. Recent operational changes recorded in the background include removal of the prior minimum age requirement (replaced with a requirement that the member has previously achieved bowel control) and removal of the phrase referencing timing after vaginal childbirth from the definition of severe, chronic fecal incontinence. The background also records the addition of a new functional requirement in section I.B.1.d and updates to coding (addition of CPT 44320 and HCPCS C1767, C1778), while emphasizing that the descriptive edits did not alter clinical intent.