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    v1.0.30
    OpenPayerPolicy UpdatesMedStar Family Choice, IncMedStar Family Choice INTERSTIM Prior Auth | OpenP…
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    CurrentMedStar Family Choice MarylandPolicy 110

    INTERSTIM for Fecal Incontinence

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    This policy governs prior authorization for INTERSTIM implantable sacral nerve stimulation therapy for chronic fecal incontinence in MedStar Family Choice members in Maryland. Coverage requires the member to meet the documented clinical criteria and applies to appropriate surgical candidates.

    Policy Summary
    PayerMedStar Family Choice Maryland
    PolicyINTERSTIM for Fecal Incontinence
    Policy CodePolicy 110
    Change TypeRevised
    Effective DateOct 1, 2011
    Last ReviewOct 1, 2016
    Next Review DateN/A
    Key ActionObtain prior authorization and submit documentation showing that all chronic fecal incontinence criteria are met.
    SourceLink
    POLICY UPDATE CHANGES

    The policy clarified the clinical indications and coverage criteria for INTERSTIM therapy for chronic fecal incontinence.

    The policy added a limitation stating that sacral nerve modulation or stimulation is experimental, investigational, and unproven for chronic constipation and chronic pelvic pain.

    The policy scope was updated to identify Maryland.

    Reference links were updated in the policy history.

    >2/weekMinimum average fecal incontinence episodes
    >6 monthsRequired chronic symptom duration

    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.

    ≥50%
    Required test-stimulation improvement
    2Unproven treatment uses

    Medical Necessity and Exclusions

    Coverage criteria for chronic fecal incontinence

    INTERSTIM for chronic fecal incontinence is authorized when ALL of the following are met:

    Chronicity and frequency: Chronic fecal incontinence averages more than two incontinent episodes per week and has lasted more than six months, or more than twelve months after vaginal childbirth.>2 episodes/week; >6 months or >12 months after vaginal childbirth
    Conventional treatment failure or intolerance: Detailed medical records document the treatments tried, the duration of each treatment, and failure or intolerance of conventional therapy, such as dietary modification, bulking treatment, and pharmacologic treatment, for a sufficient duration to fully assess efficacy.Sufficient duration to assess efficacy
    Surgical candidacy: The patient is an appropriate surgical candidate.
    Percutaneous test stimulation response: A successful percutaneous test stimulation was performed, producing at least 50% improvement in symptoms.≥50% improvement
    No excluded anorectal or gastrointestinal condition: The condition is not related to an anorectal malformation, external anal sphincter defect over 60 degrees, visible sequelae of pelvic radiation, active anal abscess or fistula, chronic inflammatory bowel disease, or constipation or constipation treatment.No listed excluded condition
    No excluded neurologic cause: The incontinence is not related to another neurologic condition, such as peripheral neuropathy or complete spinal cord injury.No listed excluded neurologic cause

    Experimental and unproven indications

    Sacral nerve modulation or stimulation is considered experimental, investigational, and unproven for the following indications:

    Unproven indications

    • Chronic constipation: Treatment is requested for chronic constipation.
    • Chronic pelvic pain: Treatment is requested for chronic pelvic pain.

    Coverage for INTERSTIM is limited when fecal incontinence is related to an anorectal malformation, an external anal sphincter defect over 60 degrees, visible sequelae of pelvic radiation, an active anal abscess or fistula, chronic inflammatory bowel disease, constipation, or constipation treatment. Coverage also requires that the incontinence not be related to another neurologic condition, such as peripheral neuropathy or complete spinal cord injury.

    Sacral nerve modulation or stimulation for chronic constipation or chronic pelvic pain is considered experimental, investigational, and unproven under this policy and is not a covered indication.

    Clinical Thresholds

    Fecal incontinence frequency
    Required frequencyMore than 2 incontinent episodes on average per week
    Applies toChronic fecal incontinence
    Coverage contextRequired criterion for authorization of INTERSTIM sacral nerve stimulation
    Symptom duration
    Required durationMore than 6 months
    Postpartum durationMore than 12 months after vaginal childbirth
    Coverage contextThe applicable duration must be documented in the medical record

    Authorization and Documentation Requirements

    Prior Authorization

    Prior Authorization Required

    Prior authorization is required for the INTERSTIM sacral nerve stimulation system for bowel incontinence. Authorization is limited to FDA-approved indications and labeled limitations.

    Billing Rule

    Process Requests Through UM

    Process requests for INTERSTIM fecal incontinence therapy through MedStar Family Choice Utilization Management (UM) under Policy 110 and the MedStar Family Choice UM Process. Off-label requests may be submitted to a Medical Director for individual consideration.

    Therapy Overview

    INTERSTIM is an implantable sacral nerve stimulation system used under this policy for chronic fecal incontinence. MedStar Family Choice requires prior authorization and limits authorization to FDA-approved indications. For chronic fecal incontinence, coverage requires documented failure or intolerance of conventional therapy, appropriate surgical candidacy, and a successful percutaneous test stimulation demonstrating at least 50% improvement in symptoms.

    Policy Terms and Thresholds

    Chronic fecal incontinence
    FrequencyMore than 2 incontinent episodes on average per week
    DurationMore than 6 months, or more than 12 months after vaginal childbirth
    Treatment historyFailure or intolerance of conventional therapy must be documented after a sufficient duration to assess efficacy
    Clinical eligibilityThe patient must be an appropriate surgical candidate and have a successful percutaneous test stimulation
    Successful percutaneous test stimulation
    Trial typePercutaneous test stimulation
    Successful response
    Policy Summary
    PayerMedStar Family Choice Maryland
    PolicyINTERSTIM for Fecal Incontinence
    Policy CodePolicy 110
    Change TypeRevised
    Effective DateOct 1, 2011
    Last ReviewOct 1, 2016
    Next Review DateN/A
    Key ActionObtain prior authorization and submit documentation showing that all chronic fecal incontinence criteria are met.
    SourceLink
    On This Page
    Medical Necessity and ExclusionsClinical ThresholdsAuthorization and Documentation RequirementsTherapy OverviewPolicy Terms and Thresholds
    Percutaneous test stimulation response
    Required responseAt least 50% improvement in symptoms
    Assessment methodPercutaneous test stimulation
    Coverage contextA successful test stimulation is required for INTERSTIM authorization
    Step Therapy

    Conventional Therapy Must Be Tried First

    Conventional therapy must be tried before authorization. The record must show failure or intolerance of dietary modification, bulking treatment, and pharmacologic treatment for a sufficient duration to fully assess efficacy.

    Documentation Required

    Document Symptom History and Prior Treatment

    Submit detailed medical records documenting the incontinence symptom history and prior treatment. Include the frequency of incontinent episodes, duration of the condition, each conventional treatment tried, how long it was used, and the patient’s response.

    Documentation Required

    Document Surgical Candidacy and Test Response

    Document that the patient is an appropriate surgical candidate and that percutaneous test stimulation was successful, defined as at least 50% improvement in symptoms.

    Denial Risk

    Failure to Meet Authorization Criteria

    Requests may be denied when authorization criteria are not met, including insufficient episode frequency, inadequate symptom duration, missing or insufficient trials of conventional therapy, or less than 50% improvement with percutaneous test stimulation.

    Denial Risk

    Excluded Underlying Conditions

    Do not authorize when incontinence is related to excluded underlying conditions, including anorectal malformation, an external anal sphincter defect over 60 degrees, visible sequelae of pelvic radiation, active anal abscess or fistula, chronic inflammatory bowel disease, constipation or constipation treatment, or another neurologic condition such as peripheral neuropathy or complete spinal cord injury.

    Denial Risk

    Unproven Treatment Indications

    Sacral nerve modulation or stimulation is considered experimental, investigational, and unproven for treatment of chronic constipation or chronic pelvic pain.

    At least 50% improvement in symptoms
    Authorization requirementA successful trial is required for INTERSTIM coverage