INTERSTIM sacral nerve stimulation for fecal incontinence
Customize your policy alerts
Sign up for medstarfamilychoicedistrictofcolumbia Policy 1404.DC alerts
Get alerted when Policy 1404.DC changes without checking for updates manually.
Monitor payer policy activity
Governs prior authorization and coverage criteria for INTERSTIM implantable sacral nerve stimulation to treat chronic fecal incontinence for MedStar Family Choice District of Columbia enrollees.
Clarified indications for coverage
Added limitation that sacral nerve modulation/stimulation is experimental, investigational and unproven for chronic constipation or chronic pelvic pain
Updated regulatory/reference links and citations
Coverage Criteria for InterStim (Sacral Nerve Stimulation)
FDA-approved coverage criteria for chronic fecal incontinence
Covered when ALL of the following are met:
Coverage excludes patients whose fecal incontinence is related to anorectal malformations (for example, congenital anorectal malformations), those with external anal sphincter defects greater than 60 degrees, and those with visible sequelae of pelvic radiation. Additional explicit exclusions include active anal abscesses or fistula, chronic inflammatory bowel disease, and incontinence attributable to other neurologic conditions such as peripheral neuropathy or complete spinal cord injury.
Sacral nerve modulation/stimulation (INTERSTIM) for the treatment of chronic constipation or chronic pelvic pain is considered experimental, investigational and unproven and is therefore not covered under this policy.
Procedure and Reference Codes
| A55835 | Local Coverage Article referenced |
| affected codes | Placeholder for specific procedure/device CPT/HCPCS codes to be used with prior authorization |
Authorization, Documentation, and Provider Requirements
Prior authorization required; nurse approvals possible
Prior authorization is required for INTERSTIM sacral nerve stimulation for bowel (fecal) incontinence. Approvals may be granted by nurse clinical operations staff if the FDA criteria are met; off-label requests may be referred to a Medical Director for individual consideration.
Conservative therapy failure/intolerance required
Patient must have failed or been intolerant to conventional therapy — including dietary modification, bulking agents, and pharmacologic treatment — for at least a sufficient duration to fully assess efficacy before INTERSTIM is considered.
- Conservative therapies listed in the policy: dietary modification, addition of bulking agents, pharmacologic treatment
- Failure or intolerance must be documented and treatment duration must be sufficient to assess efficacy
Submit detailed treatment and test documentation
Provide detailed medical records documenting which treatments were tried and for how long, evidence of failure or intolerance to conventional therapy, confirmation that the patient is an appropriate surgical candidate, and documentation of a successful percutaneous test stimulation (>= 50% symptom improvement).
- Exact treatments tried and durations
- Evidence of failure or intolerance to conservative measures
- Statement that patient is an appropriate surgical candidate
- Percutaneous test stimulation result showing at least 50% improvement
Denial triggers: off-indication use or missing documentation
Requests will be denied if they do not meet the FDA-approved indications (for example, requests for chronic constipation or chronic pelvic pain) or if required documentation of failed/adequate conservative therapy, sufficient duration, or successful percutaneous test stimulation is missing.
- Use for chronic constipation or chronic pelvic pain is considered experimental/investigational and not covered
- Missing documentation of treatments tried, durations, failure/intolerance, or percutaneous test response (>=50% improvement) may lead to denial
Background
The INTERSTIM sacral nerve stimulation system is an FDA-approved therapy for chronic fecal incontinence when specific criteria are met. Coverage is limited to patients with an average of greater than 2 incontinent episodes per week for a duration of greater than 6 months, who have documented failure or intolerance of conservative therapies for an adequate duration, who are appropriate surgical candidates, and who demonstrate a successful percutaneous test stimulation defined as at least 50% improvement in symptoms.
Definitions and Clinical Thresholds
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.