ModifiedUnitedHealthcarePolicy CS358KS.02

Sacral Nerve Stimulation for Urinary and Fecal Indications (Kansas)

Medical policy governing coverage and medical necessity criteria for sacral nerve stimulation (SNS/SNM) for urinary and fecal indications for members in Kansas aged 18 and older.

Policy Summary

PayerUnitedHealthcare

PolicySacral Nerve Stimulation for Urinary and Fecal Indications (Kansas)

Policy CodePolicy CS358KS.02

Change TypeModified — definitions and ICD-10 code updates, documentation guidance added.

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionObtain and document a successful screening trial (≥50% symptom improvement) and prior conservative therapy failure in the medical record for prior authorization.

SourceLink

POLICY UPDATE CHANGES

Replaced references to 'Sacral Nerve Stimulation' with 'Sacral Nerve Stimulation (neurostimulation).'

Added language clarifying that benefit coverage is determined by federal, state, or contractual requirements and that medical records documentation may be required to assess whether the member meets clinical criteria but does not guarantee coverage.

Added definition for Fowler's Syndrome and for Sacral Nerve Stimulation (SNS).

ICD-10 diagnosis codes R35.81, R39.191, R39.192, and R39.198 were added and codes R35.8 and R39.19 were removed for urinary indications.

≥18Age requirement

50%Screening trial threshold

3–7 daysTypical screening duration

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Chronic retention PVR

2–3 weeksBowel diary pre-test

66%Meta pooled test success

Coverage and Medical Necessity Criteria

SNS screening trial for urinary voiding dysfunction (Adults 64 18)

Covered when ALL of the following are met

Urinary indications: Lower urinary tract symptoms: overactive bladder, urge incontinence, or nonobstructive urinary retention (NOUR)

Bladder capacity of 100 ml or greater>= 100 mL

Non-neurologic origin: Urinary voiding dysfunction is not secondary to a neurologic disease origin (eg, Parkinson's disease, stroke, spinal cord injury, multiple sclerosis)

No obstruction: No bladder outlet or mechanical obstruction (eg, BPH, tumor/radiation, urethral stricture)

Refractory to conservative care: Symptoms refractory to conservative care (eg, bladder training, pelvic floor rehabilitation, pharmacologic therapy)

Patient capability: Individual capable of operating sacral nerve stimulating device

SNS permanent implantation for urinary voiding dysfunction

Covered when ALL of the following are met

Prior trial met: All criteria for SNS screening trial have been met

Trial response: Improvement in reported symptoms of 50% or greater in response to a screening trial of Sacral Nerve Stimulation>= 50%

SNS screening trial for fecal incontinence (Adults 64 18)

Covered when ALL of the following are met

Refractory to conservative care: Symptoms refractory to conservative care (eg, bowel training, bulking agents, pelvic floor rehabilitation, pharmacological therapy)

Patient capability: Individual capable of operating sacral nerve stimulating device

Non-neurologic origin: Fecal incontinence is not secondary to a neurologic disease origin (eg, Parkinson's disease, stroke, spinal cord injury, multiple sclerosis)

Not secondary to constipation: Fecal incontinence is not secondary to constipation

SNS permanent implantation for fecal incontinence

Covered when ALL of the following are met

Prior trial met: All criteria for Sacral Nerve Stimulation screening trial have been met

Trial response: Improvement in reported symptoms of 50% or greater in response to a screening trial of Sacral Nerve Stimulation>= 50%

Replacement or revision of sacral nerve stimulator

Covered when ALL of the following are met

Prior criteria met: Individual has met all the above criteria for Sacral Nerve Stimulation treatment

Device nonfunctional: Existing device is nonfunctional and either cannot be repaired or is no longer under warranty

Coverage with criteria (test-phase responder pathway)

Evidence supports coverage when ALL of the following are met (as commonly used in trials and systematic reviews):

Initial criteria: 1) Diagnosis of refractory OAB/UUI, neurogenic LUTD, fecal incontinence/LARS or other specific indication evaluated in trials; 2) Failure of conservative and pharmacologic therapies appropriate to the indication; 3) Successful test stimulation defined as ≥50% symptom reduction on diaries or validated scores

Derived from randomized trials and systematic reviews describing inclusion and responder definitions

Insufficient evidence / investigational indications

Not covered/experimental when ALL of the following apply:

Insufficient evidence indications: Chronic pelvic pain (CPP) and constipation: insufficient high-quality evidence to demonstrate efficacy; additional high-quality studies required before routine coverage

Based on statements of insufficient evidence in systematic reviews/trials

Coverage criteria for permanent SNM implantation

Covered when ALL of the following are met

Select indications and prior therapy: Indication is refractory OAB/UUI, urinary retention (including non-obstructive urinary retention / NOUR), or fecal incontinence after failure of appropriate conservative therapies (behavioral therapy, medications, biofeedback where applicable)

Supported by AUA/SUFU, EAU, ICS, AGA guidance

Trial stimulation response: Patient demonstrates clinically meaningful improvement during a trial/test stimulation (percutaneous nerve evaluation or staged trial)Typical responder definitions include >=50% symptom improvement or predefined diary criteria

Trial phase identified as most valued predictor of success

Patient capability and follow-up: Patient is cognitively able to operate the device or has supportive caregivers; patient consents to long-term surveillance and potential reoperations/device maintenance

Guidelines recommend life-long surveillance for implants

Indications with insufficient evidence

Not routinely covered / insufficient evidence when ANY of the following are present

Constipation indications: SNM for chronic constipation or slow transit constipation lacks sufficient and consistent evidence; randomized trials and systematic reviews are inconclusive or show no benefit

Multiple systematic reviews and RCTs report insufficient or conflicting evidence

Neurogenic indications with unclear evidence: Urinary voiding dysfunction and fecal incontinence secondary to neurologic disease have insufficient evidence in many contexts; careful selection and more research needed

Some studies suggest benefit in select neurogenic patients but overall evidence deemed insufficient

ASCRS position on FI and constipation

Additional specialty guidance

ASCRS guidance for fecal incontinence/constipation: ASCRS indicates SNM may be considered as a surgical option for fecal incontinence (including with sphincter defects) and may be effective for chronic constipation after failed conservative measures, though constipation indication is not FDA-approved in the U.S.; clinical evidence and candidate selection considerations should be documented.

Grade and FDA-approval status noted in citations.

Sacral Nerve Stimulation (SNS/SNM) 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. This policy therefore does not routinely support SNS for these indications in the absence of higher-quality data demonstrating clinical benefit.

Systematic reviews and recent trials have concluded that evidence is insufficient to support routine use of SNS for chronic pelvic pain and for most forms of constipation. Existing studies are heterogeneous, include few randomized controlled trials, and do not provide consistent long-term outcomes to establish clear benefit for these indications.

The policy identifies the following as absolute contraindications to permanent SNS implantation: insufficient clinical response to a therapeutic trial, inability of the individual to operate the device without supportive caregivers, and pregnancy.

Specifically, permanent implantation should not be performed when the individual is pregnant, is incapable of operating the stimulator without caregiver support, or has demonstrated an insufficient clinical response to a therapeutic (test) trial. These conditions are treated as absolute contraindications and would preclude coverage for implantation.

Coverage determinations using this policy are subject to the member’s federal, state, or contractual benefit terms, which govern in the event of any conflict. Medical records and other documentation may be requested to assess whether the member meets medical necessity criteria, and submission of documentation does not guarantee coverage when plan or regulatory terms differ.

Use of sacral nerve stimulation for Constipation and Chronic Pelvic Pain is not supported by sufficient, consistent high-quality evidence in current literature. While some trials report promising short-term results for select constipation populations, overall evidence is heterogeneous and long-term effectiveness and safety remain unclear; therefore SNS for these indications is not routinely endorsed by this policy.

Sham-controlled trials and systematic reviews have demonstrated placebo (sham) responses in some studies of fecal incontinence and constipation, with clinically meaningful symptom improvements reported in patients receiving sham stimulation. These findings underscore the importance of objective documentation of response (for example, ≥50% improvement during a supervised test period) before attributing benefit to active neuromodulation.

For constipation, including refractory idiopathic slow transit constipation or chronic functional constipation, multiple systematic reviews and randomized trials provide inconclusive or conflicting results. Some RCTs show no significant benefit versus sham, and reviews highlight heterogeneity, limited sample sizes, and variable safety and reoperation rates; on balance, evidence is not strong enough to support routine SNS for these constipation indications.

Patients with severe or rapidly progressive neurologic disease, those with an established complete spinal cord injury, or individuals who are expected to require MRI of body parts below the head are identified as relative contraindications and require individualized assessment. Such patients may not be appropriate candidates for SNS without further evaluation of risks, device compatibility, and expected benefit.

Procedure, Device and Diagnosis Codes

Procedure CPT codesCPT

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.

HCPCS/L-codesHCPCS

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.

Diagnosis ICD-10 codes (urinary and fecal indications)ICD-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 35

1/4

Codes referenced elsewhere in policy (not present in this document window)mixed

No codes listed

Referenced PMA identifiersmixed

P970004	InterStim Premarket Approval referenced
P190006	Axonics r-SNM PMA referenced
P240031	Neuspera PMA referenced

Applicable ICD-10 Diagnosis Code Changes (Urinary Indications)ICD-10

R35.81	Added ICD-10 diagnosis code for urinary indication as listed in policy
R39.191	Added ICD-10 diagnosis code for urinary indication as listed in policy
R39.192	Added ICD-10 diagnosis code for urinary indication as listed in policy
R39.198	Added ICD-10 diagnosis code for urinary indication as listed in policy
R35.8	Removed ICD-10 diagnosis code (previously listed)
R39.19	Removed ICD-10 diagnosis code (previously listed)

inv-27: Screening trial response — ≥ 50% improvement in reported symptoms

Screening trial response≥ 50% improvement in reported symptoms during the screening trial (responder defined as ≥50% symptom reduction)

DocumentationResponder status should be documented with voiding diaries or validated questionnaires as used in trials

ApplicabilityRequired prior to consideration of permanent implantation for urinary voiding dysfunction in adults ≥18

inv-28: Bladder capacity — ≥ 100 mL

Bladder capacity threshold>= 100 mL bladder capacity required for consideration of SNS screening trial

Prior Authorization, Documentation, and Operational Guidance

Prior Authorization

Prior Authorization Required

Prior authorization is required for sacral nerve stimulation (SNS/SNM) procedures and device placement. Prior authorization requests must include complete medical records that document prior conservative and pharmacologic therapies tried and failed, details of any sequencing of therapies (e.g., behavioral therapies, pelvic floor rehabilitation, bladder/bowel training, pharmacologic therapy, botulinum toxin, PTNS), and that the individual is a candidate able to operate the device. Coverage decisions reference applicable federal, state, or contractual requirements and may be adjudicated using InterQual® criteria; when InterQual® criteria are unavailable, UnitedHealthcare medical policy clinical review will be used. Medical records may be requested to substantiate medical necessity and do not guarantee approval.

Prior authorization must document: prior conservative care (behavioral therapy, pelvic floor rehab, bladder/bowel training), pharmacologic therapy trials, and sequencing of treatments (e.g., SNM, PTNS, BTX as third-line options).
If botulinum toxin (BTX) was used, document response and reasons for choosing SNM (some guidelines consider SNM after BTX failure).
Medical records must be legible, available on request, and include relevant history, physical exam, diagnostic test results, and prior treatment responses.

Prior Authorization

Key Terms and Thresholds

Sacral Nerve Stimulation (SNS), also referred to as sacral neuromodulation (SNM), involves placement of an electrode near the sacral nerve with an implanted pulse generator to modulate bladder, bowel, and pelvic floor function. SNS is typically used as a third-line therapy for refractory overactive bladder, urge incontinence, nonobstructive urinary retention, and fecal incontinence after conservative measures have failed; a temporary test stimulation period is used to identify responders prior to permanent implantation.

inv-53: Chronic Urinary Retention — PVR ≥ 300 mL persisting ≥ 6 months, documented on ≥ 2 occasions

DefinitionChronic urinary retention: postvoid residual (PVR) ≥ 300 mL persisting ≥ 6 months

Documentation standardPVR must be documented on ≥ 2 separate occasions to meet definition

Source guidanceDefinition cited from Stoffel et al., 2016 within policy definitions

inv-54: Chronic Pelvic Pain — definition summary

Policy Summary

PayerUnitedHealthcare

PolicySacral Nerve Stimulation for Urinary and Fecal Indications (Kansas)

Policy CodePolicy CS358KS.02

Change TypeModified — definitions and ICD-10 code updates, documentation guidance added.

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionObtain and document a successful screening trial (≥50% symptom improvement) and prior conservative therapy failure in the medical record for prior authorization.

SourceLink

On This Page

Lack of distorted anatomy (eg, anorectal malformation, abscess or fistula, rectal surgery)

ContextBladder capacity criterion applies to urinary voiding dysfunction indications (OAB, UUI, NOUR)

DocumentationBladder capacity should be measured and recorded in the medical record prior to trial

inv-29: Chronic urinary retention PVR threshold — ≥ 300 mL

PVR threshold>= 300 mL postvoid residual (PVR) on measurement

Duration requirementPVR ≥ 300 mL must persist for ≥ 6 months

ConfirmationPVR must be documented on ≥ 2 separate occasions

inv-30: Test-phase success threshold — ≥ 50% reduction in target symptom score or episodes

Test-phase success threshold>= 50% reduction in target symptom score or episodes during the test phase (e.g., UUI episodes or LARS score)

Trial-to-implant pathwayParticipants achieving this threshold in randomized and controlled trials proceeded to permanent implant

MeasurementSuccess measured by diaries or validated symptom scores as used in trials (eg, voiding diaries, LARS score)

inv-31: Test response threshold — >= 50% improvement in one or more troublesome urinary or bowel parameters during PNE or Stage 1

Test response threshold>= 50% improvement in one or more troublesome urinary or bowel parameters during PNE or Stage 1 test period

ImplicationIndividuals meeting this threshold may be offered complete system implantation

Test typesApplies to PNE (percutaneous nerve evaluation) and Stage 1 staged testing

Test-Period Response Required for Implantation

For permanent implantation, prior authorization must confirm that a successful test-phase (trial stimulation) was performed and that the individual achieved a clinically meaningful response during the test period. A responder is typically defined as achieving ≥50% improvement in the target symptom(s) (e.g., reduction in urinary incontinence episodes, improvement in bowel diary measures) during the screening trial.

Documentation must include objective and/or patient-reported outcome measures demonstrating ≥50% symptom reduction during the trial.
For urinary indications, record baseline and post-trial symptom counts (e.g., UUI episodes/day).
For fecal incontinence, include bowel diary entries and measures showing ≥50% improvement.

Documentation Required

Pre-Test Documentation for Bowel Indications

Pre-test documentation requirements vary by indication. For bowel dysfunction, a 2–3 week bowel diary is recommended prior to the SNM test phase. Clinicians may consider anorectal physiology testing (manometry, anorectal sensation, volume tolerance, compliance) to further characterize dysfunction and guide management.

Bowel indications: 2–3 week bowel diary required before test stimulation; include baseline frequency, urgency, incontinence episodes, and stool consistency.
Consider anorectal physiology testing results when available to support the diagnosis and treatment plan.

Step Therapy

Conservative Therapy and Therapy Sequencing

Conservative therapy must have failed before considering SNS/SNM. Conservative care includes behavioral therapies, pelvic floor rehabilitation/biofeedback, bowel/bladder training, bulking agents (for FI), and appropriate pharmacologic therapy. SNS, PTNS, and intradetrusor BTX are considered third-line options after failure of these conservative and medical therapies; document prior therapies and durations in the authorization request.

Document trials of conservative measures and pharmacologic agents and the duration/response of each.
Specify sequencing: SNS often offered after failure of conservative care and may be considered after BTX failure per some guidelines; note that guideline recommendations vary.

Denial Risk

Evidence Quality Risks and Denial Triggers

Evidence quality limitations and heterogeneity in study designs are recognized. Requests may be denied if the clinical evidence does not support medical necessity for the requested indication (for example, SNS for constipation or chronic pelvic pain is considered unproven). Insufficient documentation of prior therapies, inadequate test-phase response, or absence of required medical records are grounds for denial.

SNS for constipation and chronic pelvic pain is considered unproven and not medically necessary due to insufficient evidence.
Lack of comparative trials, small sample sizes, and heterogeneous outcome measures in the literature may affect coverage determinations.
Requests lacking required documentation of prior therapy failure or test-phase response may be denied.

Denial Risk

Absolute Contraindications

Absolute contraindications must be documented and will preclude coverage. These include insufficient clinical response to the therapeutic trial (i.e., failure to achieve the defined responder threshold), inability of the individual to operate the device without the availability of supportive caregivers, and pregnancy.

Insufficient response to trial stimulation (failure to achieve ≥50% symptom improvement) — absolute contraindication to permanent implantation.
Patient incapable of operating device and no available caregivers to assist — absolute contraindication.
Pregnancy at the time of implantation — absolute contraindication.

Note

Trial Stimulation Expectations and Responder Documentation

Operational guidance: the screening/trial phase is expected prior to permanent implantation. Typical test durations are: percutaneous nerve evaluation (PNE) ~7 days for bladder indications and 10–21 days for bowel indications; Stage 1 (tined lead) testing is typically 2–3 weeks and may be repeated at physician discretion. Both sensory and motor responses during the trial should be considered when assessing likelihood of long-term success.

Test success is generally defined as ≥50% improvement during the PNE or Stage 1 test period.
Stage 1 testing may be used when a longer trial is necessary or when PNE is equivocal.

Prior Authorization

Prior Authorization and Criteria Guidance

Prior authorization and clinical review will follow InterQual® criteria when applicable. If InterQual® lacks applicable criteria, UnitedHealthcare medical policy clinical review will be used in conjunction with federal, state, and contractual benefit provisions. Medical records supporting medical necessity must be available upon request and should include trial documentation, objective measures of response, and clinician assessment.

Coverage decisions reference InterQual® as primary criteria; alternate medical review is used if InterQual® criteria are not applicable.
Medical records may be required to verify compliance with clinical criteria and benefit terms.

Chronic Pelvic Pain (CPP): persistent or recurrent episodic pelvic pain associated with lower urinary tract, sexual, bowel, or gynecological symptoms without proven infection or other obvious pathology

Clinical contextCPP definition references Fall et al., 2010 as cited in policy

Coverage implicationPolicy notes lack of evidence supporting SNS for non-IC/BPS CPP; CPP may be excluded from routine coverage

inv-55: Sacral Nerve Stimulation (SNS/SNM) — definition of therapy

Therapy definitionSacral Nerve Stimulation (SNS/SNM): placement of a small electrode tip near the sacral nerve with an implanted pulse generator to modulate bladder and pelvic floor function

Alternate namesAlso referred to as Sacral Neuromodulation (SNM) or Urologic Nerve Stimulation

IndicationsUsed to treat urinary incontinence, urgency/frequency, non-obstructive urinary retention, and fecal incontinence

inv-56: Successful test stimulation — defined in trials as ≥50% improvement in target symptoms

Successful test stimulationDefined in trials as ≥ 50% improvement in urinary incontinence or urinary frequency symptoms or return to normal voiding (<8 voids/day)

Trial outcomesSuccessful test stimulation was used as the criterion for proceeding to permanent implantation in clinical trials

Measurement methodsResponser definitions based on voiding diaries and validated questionnaires used in trials

inv-57: Trial phase / test stimulation — temporary stimulation period (PNE, Stage 1) used to predict therapeutic success

DefinitionTrial phase/test stimulation: temporary stimulation period (eg, percutaneous nerve evaluation) used to predict likelihood of therapeutic success prior to permanent implantation

ValueICS identifies the trial phase as the most valued tool for predicting SNM success

UseApplied for both urinary and bowel indications to identify responders before full implant

inv-58: Absolute contraindications — includes insufficient trial response, inability to operate device, pregnancy

Absolute contraindications — key itemsIncludes insufficient clinical response to a therapeutic trial, inability to operate the device without supportive caregivers, and pregnancy

ConsequencePresence of these absolute contraindications would preclude permanent implantation and may trigger denial

Guideline gradeListed as absolute contraindications in policy (Level IV; Grade C per cited guidance)

inv-59: PNE / Stage 1 test period — typical durations (PNE 7 days bladder / 10–21 days bowel; Stage 1 2–3 weeks)

Typical PNE durationsPNE test stimulation period typically 7 days for bladder indications and 10–21 days for bowel indications

Stage 1 durationStage 1 test period is typically 2–3 weeks and may be used when a longer screening duration is desired

Repeat testingA repeat Stage 1 test may be performed at physician discretion if initial PNE is questionable

inv-60: Successful test response — achievement of ≥50% improvement in one or more troublesome urinary or bowel parameters during PNE or Stage 1

Successful test responseAchievement of ≥50% improvement in one or more troublesome urinary or bowel parameters during PNE or Stage 1

Implant considerationIndividuals meeting this criterion may be offered complete system implantation per ICS guidance

AssessmentClinicians should consider both sensory and motor responses when evaluating success

inv-61: Fowler's Syndrome — definition added to policy; exact text in source

Definition textFowler's Syndrome: characterized by large bladder capacity, reduced sensation, increased maximal urethral closure pressure, and detrusor underactivity; often occurs in post-menarche young women and associated with triggers such as gynecological surgery, childbirth, or acute medical events (Szymański et al., 2021)

Policy updateFowler's Syndrome definition was added to the policy in the 01/01/2026 revision

inv-62: Sacral Nerve Stimulation (SNS) terminology — standardized naming and synonyms noted

TerminologySacral Nerve Stimulation (SNS) standardized term; also referred to as Sacral Neuromodulation (SNM) or Urologic Nerve Stimulation

Policy languagePolicy revisions replaced prior references with 'Sacral Nerve Stimulation (neurostimulation)'

Clinical descriptionImplantation of electrode near sacral nerve with implanted pulse generator to modulate bladder and pelvic floor function