CurrentUnitedHealthcarePolicy CSNCT0358.02

Sacral Nerve Stimulation for Urinary and Fecal Indications (for North Carolina Only) – Community Plan Medical Policy

North Carolina–only UnitedHealthcare community plan medical policy that defines medical necessity criteria for sacral nerve stimulation (SNS) screening trial, permanent implantation, replacement/revision for urinary voiding dysfunction and fecal incontinence in adults (≥18 years). Also states noncoverage for constipation and chronic pelvic pain due to insufficient evidence.

Policy Summary

PayerUnitedHealthcare

PolicySacral Nerve Stimulation for Urinary and Fecal Indications (for North Carolina Only) – Community Plan Medical Policy

Policy CodePolicy CSNCT0358.02

Change TypeRevised / Added definitions and documentation requirements

Effective DateDec 1, 2025

Next Review Date

Key ActionDocument in the medical record that all clinical criteria are met, including refractory symptoms, absence of neurologic or mechanical cause, capability to operate the device, and ≥50% improvement on trial to support coverage.

SourceLink

POLICY UPDATE CHANGES

12/01/2025: Replaced references to 'Sacral Nerve Stimulation' with 'Sacral Nerve Stimulation (neurostimulation)'; removed a reference link under Medical Records Documentation Used for Reviews; added language requiring medical record documentation that fully supports medical necessity and that documentation be legible and available upon request.

12/01/2025: Added definition of 'Sacral Nerve Stimulation (SNS) [Also Known as Sacral Neuromodulation (SNM) or Urologic Nerve Stimulation]'.

12/01/2025: Updated Clinical Evidence, FDA, and References sections to reflect current information; archived previous policy version CSNCT0358.01.

05/01/2026: Updated reference link to reflect the current policy title for Gastrointestinal Disorders Diagnostic Procedures (for North Carolina Only).

2Indications with proven medical necessity (urinary, fecal)

Coverage Summary

This policy applies to North Carolina UnitedHealthcare Community Plan and addresses Sacral Nerve Stimulation (SNS/SNM) for adults (age ≥ 18). Policy number is CSNCT0358.02 with an effective date of December 1, 2025. The policy defines medical necessity criteria for SNS screening trials, permanent implantation, and replacement/revision for urinary voiding dysfunction and fecal incontinence in adults. The coverage stance is mixed: SNS screening trials and permanent implantation are described as proven and medically necessary for specified urinary and fecal indications when all clinical criteria (including thresholds) are met, while SNS for Constipation and Chronic Pelvic Pain is explicitly stated as not medically necessary due to insufficient evidence of safety and/or efficacy.

Key thresholds and test-phase facts

Minimum bladder capacity for screening trial>= 100 mL

Screening/permanent implant symptom improvement threshold>= 50% improvement on test trial

PNE (test) duration — bladderTypically 7 days

PNE (test) duration — bowelTypically 10–21 days

Stage 1 test durationTypically 2–3 weeks (repeat Stage 1 at physician discretion)

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

Medical Necessity Criteria

SNS screening trial for urinary voiding dysfunction (medically necessary)

Sacral Nerve Stimulation (SNS) screening trial is proven and medically necessary for treating urinary voiding dysfunction when ALL of the following criteria are met:

ALL of the following

Lower urinary tract symptoms, as indicated by one or more of the following: Overactive bladder symptoms (also known as urgency frequency syndrome); Urge Incontinence; Nonobstructive urinary retention (NOUR).
Bladder capacity of 100 mL or greater>=100 mL
Urinary voiding dysfunction is not secondary to a neurologic disease origin (e.g., Parkinson's disease, stroke, spinal cord injury, multiple sclerosis).

Test-Phase and Implantation Decision Criteria

General test-phase and implantation decision criteria (per guideline statements)

Covered when ALL of the following are met:

ALL of the following

Individual has refractory symptoms (urinary or bowel) after adequate conservative and medical therapies (e.g., ≥3 months trial for FI per AGA recommendation; conservative/medical therapy failure for OAB/UUI per multiple guidelines)
Individual demonstrates ≥50% improvement in one or more troublesome urinary or bowel parameters during PNE or Stage 1 test period>= 50% improvement
Stage/duration: PNE typical test stimulation period — bladder: 7 days; bowel: 10–21 days; Stage 1 test period typically 2–3 weeks (repeat Stage 1 at physician discretion)PNE bladder: 7 days; PNE bowel: 10-21 days; Stage1: 2-3 weeks

Provider Actions & Documentation Requirements

Documentation Required

Support medical necessity with medical record documentation

Support medical necessity with clear, contemporaneous medical record documentation. Include relevant history, physical exam, prior conservative treatments and duration, diagnostic test results, and documentation that the individual is capable of operating the device.

History: symptoms, duration, prior therapies and response, comorbidities (including exclusionary neurologic conditions)
Physical examination: relevant pelvic/abdominal/neurologic exam findings
Diagnostic tests: bladder diary, post-void residual (PVR) volumes, urodynamics (if performed), anorectal manometry or endoanal ultrasound for fecal indications when available
Conservative therapy record: documentation of trials and inadequate response (e.g., bladder training, pelvic floor rehab, medications, bowel regimen)
Screening trial documentation: dates and procedures for test-phase, percent improvement in symptoms, and objective diary entries or validated symptom scores

Coding

Relevant CPT / HCPCS procedure codes (reference only)CPT

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

Relevant HCPCS device codes (reference only)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

Urinary diagnosis codes referencedICD-10

N32.81	Overactive bladder
N32.9	Bladder disorder, unspecified
N39.3	Stress incontinence (female) (male)
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

Fecal diagnosis codes referencedICD-10

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

Not on NC Medicaid Fee Schedule (noted)CPT|HCPCS

0784T
0785T
0786T
0787T
L8679
L8680
L8682
L8685
L8686
L8687

1–10 of 11

1/2

Background & Evidence

Sacral nerve stimulation (SNS/SNM) is an implanted neuromodulation therapy that places an electrode near the sacral nerve (typically S3) to modulate bladder and bowel function. It is used after failed conservative and pharmacologic treatments for conditions including overactive bladder, urge urinary incontinence, and non-obstructive urinary retention, and is also used for fecal incontinence. Individuals typically undergo a temporary screening trial (PNE or Stage 1) — commonly 3–7 days for the initial percutaneous evaluation (with Stage 1 often lasting 2–3 weeks when used) — to assess response before permanent implantation. A common success definition for the screening trial is ≥50% improvement in one or more troublesome urinary or bowel parameters; pooled and guideline-supported evidence (systematic reviews and meta-analyses, and assessments from Hayes and ECRI) report pooled test-phase success rates around ~66% and pooled permanent SNM success rates in the ~83–84% range, supporting efficacy for selected populations.

Selected evidence metrics

Pooled screening (test-phase) success rate~66.2% pooled test stimulation success (van Ophoven meta-analysis)

Pooled permanent SNM success rate~82.9% - 84.2% (meta-analytic pooled estimates)

Common device-related adverse event rates (reported)Loss of effectiveness ~4.7%; infection ~3.6%; implant site pain ~3.2%; lead migration ~3.2%

Revision History

12/01/2025revised

Material change: Replaced references to 'Sacral Nerve Stimulation' with 'Sacral Nerve Stimulation (neurostimulation)'; removed a reference link under Medical Records Documentation Used for Reviews; added requirement that the patient's medical record must contain documentation that fully supports medical necessity, be legible, maintained in the record, and made available upon request. Also annotated that certain CPT/HCPCS codes are not on the NC Medicaid Fee Schedule and may not be covered.

12/01/2025added

Added definition of 'Sacral Nerve Stimulation (SNS) [Also Known as Sacral Neuromodulation (SNM) or Urologic Nerve Stimulation]'.

12/01/2025revised

Policy Summary

PayerUnitedHealthcare

PolicySacral Nerve Stimulation for Urinary and Fecal Indications (for North Carolina Only) – Community Plan Medical Policy

Policy CodePolicy CSNCT0358.02

Change TypeRevised / Added definitions and documentation requirements

Effective DateDec 1, 2025

Next Review Date

SourceLink

On This Page

Preoperative counseling and considerations

Documented discussion of risks, benefits, and alternatives to SNS, including surgical risks, device-related complications, and need for future programming and follow-up.
Expectation setting regarding the need for a staged approach (screening trial followed by permanent implantation only if trial is successful) and potential need for future revision or replacement procedures.
Assessment and documentation that the individual can operate the device and attend follow-up visits for device programming and management.
Review of relevant comorbidities and contraindications (e.g., active infection, coagulopathy, implanted incompatible devices) and consideration of wound-healing capacity and anesthesia risk.

SNS permanent implantation for urinary voiding dysfunction (medically necessary)

Sacral Nerve Stimulation permanent implantation for treating urinary voiding dysfunction is proven and medically necessary when ALL of the following criteria are met:

ALL of the following

All criteria for Sacral Nerve Stimulation screening trial have been met.
Improvement in reported symptoms of 50% or greater in response to a screening trial of Sacral Nerve Stimulation.>=50%
Preoperative counseling and documentation as described above, including baseline symptom documentation and ability to operate the device.

Successful outcome definition

For permanent implantation candidacy, documented >=50% reduction in target symptom frequency or severity compared with baseline (e.g., reduction in incontinence episodes, urgency/frequency episodes, or improvement in voiding parameters).>=50%
Continuation of clinical benefit on follow-up visits and programming assessments as appropriate.

SNS screening trial for fecal incontinence (medically necessary)

Sacral Nerve Stimulation screening trial is proven and medically necessary for treating Fecal Incontinence when ALL of the following criteria 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).

Preoperative counseling and considerations

Documented discussion of risks, benefits, and alternatives to SNS for fecal incontinence, including possible need for bowel regimen optimization and continued conservative measures.
Assessment that the individual can operate the device and attend necessary follow-up for programming and management.
Review of comorbid conditions and contraindications that may impact outcomes or wound healing.

Successful outcome definition

Baseline documentation of fecal incontinence frequency and severity (e.g., bowel diary, number of incontinent episodes) to allow comparison after trial.
Improvement during the screening trial defined as a >=50% reduction in fecal incontinence episodes or comparable validated symptom score improvement.>=50%

SNS permanent implantation for fecal incontinence (medically necessary)

Sacral Nerve Stimulation permanent implantation for treating Fecal Incontinence is proven and medically necessary when ALL of the following criteria are met:

ALL of the following

All criteria for Sacral Nerve Stimulation screening trial have been met.
Improvement in reported symptoms of 50% or greater in response to a screening trial of Sacral Nerve Stimulation.>=50%
Preoperative counseling and documentation as described above, including baseline symptom documentation and ability to operate the device.

Successful outcome definition

For permanent implantation candidacy, documented >=50% reduction in fecal incontinence episodes or validated score improvement compared with baseline.>=50%
Sustained clinical benefit on follow-up visits and device programming assessments.

Preoperative counseling and considerations

Discussion of expectations regarding bowel regimen adjustments, potential need for adjunctive therapies, and long-term device management.

SNS replacement or revision (medically necessary)

Sacral Nerve Stimulator replacement or revision is considered medically necessary when ALL of the following are met:

ALL of the following

The individual has met criteria for SNS therapy for the original indication (urinary voiding dysfunction or fecal incontinence) as described above.
The existing device is nonfunctional and either cannot be repaired or is no longer under warranty.
Documentation that replacement or revision is expected to restore clinically meaningful benefit based on prior response and current evaluation.

Preoperative counseling and considerations

Documentation of device interrogation and attempts at nonoperative correction (e.g., reprogramming) when applicable prior to revision or replacement.
Discussion of risks specific to revision/replacement procedures and anticipated device longevity and warranty status.

Successful outcome definition

For replacement/revision, documentation that prior device provided clinically meaningful benefit (e.g., >=50% symptom improvement) and that replacement is likely to restore that benefit.>=50%

SNS for constipation and chronic pelvic pain (not medically necessary)

Sacral Nerve Stimulation for the treatment of Constipation and Chronic Pelvic Pain is considered unproven and not medically necessary due to insufficient evidence of safety and/or efficacy.

ALL of the following

SNS for Constipation is considered not medically necessary (unproven) due to insufficient evidence of safety and efficacy.
SNS for Chronic Pelvic Pain is considered not medically necessary (unproven) due to insufficient evidence of safety and efficacy.

Preoperative counseling and considerations

If SNS is considered in investigational contexts, informed consent must document the experimental nature of the therapy and lack of established efficacy for constipation or chronic pelvic pain.

Successful outcome definition

Not applicable as therapy is considered investigational/not medically necessary; any use should be within approved investigational protocols with predefined outcome measures.

Indications with sufficient/strong evidence per guidelines (coverage-favorable)

Guideline-endorsed indications where SNS/SNM is recommended or considered:

ANY of the following

Overactive bladder (OAB) / Urgency urinary incontinence (UUI) refractory to anticholinergic or beta-3 agonist therapy — offer SNM (AUA/SUFU, EAU, EAU female LUTS)
Urinary retention / Non-obstructive urinary retention (NOUR) and Fowler's syndrome — SNM can be offered (ICS, EAU)
Fecal incontinence (FI) refractory to conservative measures — consider SNM (ACG strong recommendation; ICS second-line recommendation)
Combined urinary and bowel symptoms — SNM is preferred therapy for appropriate individuals (ICS)
Underactive bladder (UAB) refractory to conservative measures in women — offer SNM (EAU female LUTS)
Men with detrusor underactivity (DU) and no benign prostatic obstruction — offer test-phase SNM (EAU male LUTS)

Indications with insufficient or conflicting evidence (coverage-restricted/conditional)

Evidence is insufficient or conflicting; SNS not clearly supported for routine coverage for these:

ANY of the following

Constipation / Slow transit constipation (STC) — RCTs show conflicting results; overall evidence insufficient to support SNS for constipation
Chronic pelvic pain (CPP) — insufficient high-quality evidence; more RCTs needed
Urinary voiding dysfunction and fecal incontinence secondary to neurologic disease origin — evidence insufficient though some studies show benefit in selected neurogenic patients; careful selection required

Test-phase success definition and screening

ALL of the following

Success during PNE or Stage 1 defined as ≥50% improvement in one or more troublesome urinary or bowel parameters>= 50% improvement
PNE test duration: bladder ~7 days; bowel 10–21 daysPNE bladder: 7 days; PNE bowel: 10-21 days
Stage 1 test duration: typically 2–3 weeks; repeat Stage 1 possible at physician discretionStage1: 2-3 weeks
Clinician should consider both sensory and motor responses important for success

Screening for success during the test period

Covered when the following test-phase success criteria are met to proceed to full implantation:

ALL of the following

Individuals who achieve 50% improvement in one or more of their troublesome urinary or bowel parameters during the PNE or Stage 1 test period may be offered complete system implantation.>= 50% improvement
PNE (percutaneous nerve evaluation) test stimulation period duration: typically seven days for bladder indications and 10-21 days for bowel indications.PNE bladder: 7 days; PNE bowel: 10-21 days
Stage 1 test period duration: typically 2-3 weeks; Stage 1 testing may be tried if PNE is questionable or when a longer test period is required; repeat Stage 1 testing may be performed at physician's discretion.Stage1: 2-3 weeks
Clinician should consider both sensory and motor responses important for success.

Prior Authorization

Screening trial and permanent implantation require meeting policy clinical criteria

Both screening trial and permanent implantation require meeting the policy's clinical criteria. Prior authorization (when applicable) and the medical record must explicitly document that all required criteria are met before proceeding to implantation.

Document that all screening-trial eligibility requirements in the policy were met prior to trial initiation
For permanent implantation, document that screening-trial success (≥50% improvement) was achieved and recorded in the medical record

Documentation Required

Document trial-phase response

Document the trial-phase response in the medical record. The record must show an objective or patient-reported improvement of ≥50% from baseline during the test phase prior to permanent implantation.

Acceptable documentation formats: bladder/bowel diary entries, validated symptom scores (e.g., number of incontinence episodes), clinician progress notes describing percentage improvement, or device interrogation/test reports
Include dates of trial start and end, method of trial (percutaneous vs staged), and who assessed response

Billing Rule

State fee schedule note for some HCPCS codes

State fee schedule note: certain HCPCS / CPT codes listed in this policy are not on the North Carolina Medicaid Fee Schedule and therefore may not be covered by the State program. Verify state-specific reimbursement prior to billing.

Codes not on NC Medicaid Fee Schedule: 0784T, 0785T, 0786T, 0787T, L8679, L8680, L8682, L8685, L8686, L8687, L8688

Denial Risk

Risk of noncoverage for insufficient response

There is a risk of noncoverage if the individual does not demonstrate an adequate response to the screening trial. Proceed to permanent implantation only when the test-phase criteria and documentation requirements are fully met.

Do not perform permanent implantation without documented ≥50% improvement during the screening trial
Insufficient or missing trial documentation may result in claim denial

Documentation Required

Pre-implant evaluation and selection

Perform a comprehensive pre-implant evaluation to confirm indication and eligibility per policy. Document exclusion of neurologic causes, absence of mechanical obstruction, bladder capacity (when required), and that conservative therapies have been tried and failed.

Confirm age ≥18 years and indication (urinary or fecal) consistent with policy
Document bladder capacity ≥100 mL for urinary indications when required and PVR measurements as indicated
Record prior conservative treatments and durations

Documentation Required

Counseling and informed consent

Counsel the individual about risks, benefits, alternatives, and the staged nature of therapy (trial phase followed by permanent implantation if successful). Document that informed consent discussion occurred and that the individual understands device management and expectations.

Explain trial success threshold (≥50% improvement) and implications for permanent implantation
Document informed consent specific to trial and possible permanent device placement

Documentation Required

Medical record documentation requirement

Maintain complete medical record documentation to support medical necessity decisions and any prior authorization requests. Include all elements listed above and ensure trial-phase success is clearly documented before billing for permanent implantation.

Keep contemporaneous notes of symptom frequency/severity, objective test results, and patient-reported outcomes
Retain device programming logs or interrogation reports when available