Sacral Nerve Stimulation for Urinary and Fecal Indications (for North Carolina Only)
This policy governs coverage criteria and coding for sacral nerve stimulation (also sacral neuromodulation) for urinary voiding dysfunction and fecal incontinence for members in North Carolina aged 18 and older.
Policy Summary
PayerUnitedHealthcare
PolicySacral Nerve Stimulation for Urinary and Fecal Indications (for North Carolina Only)
Policy CodePolicy CSNCT0358.02
Change TypeDocumentation and coding clarificationsminor wording and reference updates
Effective DateDecember 1, 2025
Next Review DateN/A
Key ActionEnsure medical records fully document history, physical exam, and diagnostic test results to support medical necessity and prior authorization decisions.
Added language that the patient's medical record must contain documentation that fully supports medical necessity, including history, physical exam, and diagnostic test results; documentation must be legible and available upon request.
Added notation that specific CPT/HCPCS device and lead codes are not on the North Carolina Medicaid Fee Schedule and therefore may not be covered by the NC Medicaid Program.
Updated reference link to reflect the current policy title for Gastrointestinal Disorders Diagnostic Procedures (for North Carolina Only).
Replaced references to 'Sacral Nerve Stimulation' with 'Sacral Nerve Stimulation (neurostimulation)'.
Added a definition of 'Sacral Nerve Stimulation (SNS) [Also Known as Sacral Neuromodulation (SNM) or Urologic Nerve Stimulation]'.
Updated Clinical Evidence, FDA, and References sections to reflect the most current information and archived prior policy version CSNCT0358.01.
≥18age applicability
50%
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screening trial response threshold
≥100 mLminimum bladder capacity
≥300 mLPVR threshold
11NC Medicaid codes not on fee schedule
2026-05-01most recent policy revision date
Coverage Criteria for Sacral Nerve Stimulation
SNS screening trial for urinary voiding dysfunction (INITIAL)
Covered when ALL of the following are met
Adult and symptoms: Individual is ≥ 18 years of age AND has lower urinary tract symptoms such as overactive bladder, urge incontinence, or nonobstructive urinary retention (NOUR)
Bladder capacity is 100 mL or greater>= 100 mL
Not neurologic origin: Urinary voiding dysfunction is not secondary to a neurologic disease origin (e.g., Parkinson's disease, stroke, spinal cord injury, multiple sclerosis)
No obstruction: No bladder outlet or mechanical obstruction (e.g., BPH, tumor/prior radiation obstruction, urethral stricture)
Refractory to conservative care: Symptoms refractory to conservative care (e.g., bladder training, pelvic floor rehabilitation, pharmacologic therapy)
Operability: Individual is capable of operating sacral nerve stimulating device
Permanent SNS implantation for urinary voiding dysfunction (CONTINUATION)
Covered when ALL of the following are met
Screening 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 SNS>= 50%
SNS screening trial for fecal incontinence (INITIAL)
Covered when ALL of the following are met
Refractory to conservative care: Symptoms refractory to conservative care (e.g., bowel training, bulking agents, pelvic floor rehabilitation, pharmacological therapy)
Operability: Individual capable of operating sacral nerve stimulating device
Not neurologic origin: Fecal incontinence is not secondary to a neurologic disease origin (e.g., Parkinson's disease, stroke, spinal cord injury, multiple sclerosis)
Not secondary to constipation: Fecal incontinence is not secondary to constipation
Permanent SNS implantation for fecal incontinence (CONTINUATION)
Covered when ALL of the following are met
Screening trial met: All criteria for SNS screening trial for fecal incontinence have been met
Trial response: Improvement in reported symptoms of 50% or greater in response to a screening trial of SNS>= 50%
Replacement or revision of sacral nerve stimulator
Considered medically necessary when ALL of the following are met
Prior criteria met: Individual has met all indications criteria for SNS
Device nonfunctional or not repairable: Existing device is nonfunctional and either cannot be repaired or is no longer under warranty
Not medically necessary / unproven
Constipation and chronic pelvic pain: SNS for treatment of Constipation and Chronic Pelvic Pain is considered unproven and not medically necessary due to insufficient evidence of safety and/or efficacy
Evidence-based indication groups
Indication-specific evidence and commonly used selection criteria (test-phase) supporting SNM:
General selection for permanent SNM: Candidate must have an appropriate clinical indication (e.g., refractory overactive bladder, urinary retention, fecal incontinence, LARS) and demonstrate successful test stimulation (commonly >=50% symptom improvement or return to <8 voids/day)>=50% improvement
Test-phase response predictive of permanent implantation success
Urinary overactive bladder (OAB): Evidence from randomized trials, systematic reviews and meta-analyses demonstrates SNM reduces micturition frequency and incontinence episodes and may be more efficacious than PTNS and comparable to onabotulinum toxin for some outcomes; consider SNM when behavioral and pharmacologic therapies have failed
Short-term (12-week) efficacy prominent in RCTs; long-term data supportive in systematic reviews
Neurogenic lower urinary tract dysfunction (nLUTD): Meta-analyses report pooled test stimulation success ~66% and pooled permanent SNM success ~84%; success varies by neurogenic condition (e.g., nDO 61%, neurogenic NOUR 52%)
Indication-based coverage criteria
Coverage stance and criteria based on guideline recommendations and evidence summaries in the document.
Overactive bladder (OAB)/Urinary urgency urinary incontinence (UUI): Offer SNS for patients with OAB/UUI refractory to behavioral and medical therapy (third-line), after documented inadequate response or intolerance to pharmacotherapy/behavioral therapy; patients must be appropriate surgical candidates and able to manage the device and follow-up.documented failure of conservative and medical therapy
Supported by AUA/SUFU (2023), EAU, and ICS statements; trial phase predicts success (Level II evidence).
Fecal incontinence (FI): Consider SNS for individuals with moderate or severe FI who have failed a three-month (or longer) trial of conservative measures and biofeedback and have no contraindications.>=3 months conservative therapy including biofeedback
Supported by ACG and AGA best practice advice and guideline statements (strong recommendation for FI per ACG).
Guideline-supported indications (conditional on failed conservative therapy and trial success)
Covered when guideline-specified conditions are met (per EAU, ICS, NICE, ASCRS):
Refractory OAB/UUI
Evidence of trial success: Achieves >=50% improvement during PNE or Stage 1 test period>=50% improvement
PNE typically 7 days (bladder), Stage 1 typically 2-3 weeks
Urinary retention (NOUR): Individuals with chronic non-obstructive urinary retention who have failed conservative treatments may be candidates for SNMfailed conservative therapy
NICE and ICS support SNM for NOUR
Fecal incontinence (FI): Individuals with bothersome FI who have failed conservative measures may be offered SNM; anal sphincter defect is not an absolute contraindication
Sacral Nerve Stimulation (SNS) 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. The policy specifies that routine coverage for these indications is not supported by available high-quality data and thus SNS should not be used for these indications in routine clinical practice.
Individuals with chronic refractory nonobstructive urinary retention (NOUR) who fail to demonstrate an adequate response during the initial SNS testing phase are frequently not candidates for permanent implantation. Evidence assessments note that inadequate test-phase response is a common reason to withhold permanent SNS and that permanent implantation should be reserved for those who meet test-phase success criteria and other candidate selection requirements.
Routine coverage for sacral neuromodulation (SNM) to treat chronic functional constipation, including refractory idiopathic slow transit constipation, is not supported because the evidence is insufficient and conflicted. Randomized and systematic-review level data include trials with conflicting results and cross-over RCTs showing no consistent benefit of active stimulation over sham; therefore SNM for constipation should be limited to research settings or highly selected cases rather than routine clinical use.
Absolute contraindications to proceeding with permanent SNS include insufficient clinical response to a therapeutic trial (i.e., failure to meet test-phase success thresholds), and inability of the individual to operate the device without supportive caregivers. Pregnancy is also identified as an absolute contraindication. Relative contraindications include severe or rapidly progressive neurologic disease, established complete spinal cord injury, an expected need for MRI of body parts below the head, and abnormal sacral anatomy.
Certain CPT and HCPCS codes referenced for SNS procedures and devices are noted as not appearing on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the North Carolina Medicaid Program. The policy highlights this coding/payment consideration and lists specific codes in the policy history and coding sections.
Use of SNS for Constipation and Chronic Pelvic Pain is considered unproven and not medically necessary. The policy states that evidence for these indications is limited, heterogeneous, and does not consistently demonstrate durable clinical benefit, so routine coverage is not supported.
There is insufficient evidence to support SNM for treating chronic pelvic pain (CPP) as a general recommendation. Systematic reviews and available studies are heterogeneous, with few randomized controlled trials; further high-quality randomized studies in homogeneous CPP populations are required before SNM can be recommended broadly for CPP.
Available randomized trial evidence does not support routine transition to permanent SNM implantation for individuals with refractory constipation who initially responded to temporary stimulation. Cross-over RCTs and systematic reviews have shown no consistent advantage of active stimulation over sham in some trials, and long-term effectiveness remains unclear; therefore permanent implantation for constipation is not supported by current randomized evidence.
SNM for constipation is not currently FDA-approved for this indication in the United States, and the evidence base is insufficient to support routine coverage for chronic constipation. The policy emphasizes that SNM for constipation should not be considered a standard covered indication outside of research or select circumstances given the lack of regulatory approval and inconsistent clinical trial outcomes.
Coding and Billing
Prior Authorization
Prior Authorization and Documentation Requirements
Prior Authorization Required: Prior authorization is required for sacral nerve stimulation (SNS) screening trials, permanent SNS implantation, and associated devices. Requests must include documentation of indication, prerequisite conservative therapies, candidate suitability, and documented test-phase success (screening trial results). Prior authorization is also required for procedures and devices listed in the code tables below.
Provider must document that conservative therapy and/or medical management was tried and failed unless medically contraindicated (e.g., bladder training, pelvic floor rehabilitation, pharmacologic therapy for urinary indications; bowel training, bulking agents, pelvic floor rehab, pharmacologic therapy for fecal incontinence).
Prior authorization must include records demonstrating specialist review (urology, urogynecology, or colorectal surgery as appropriate) and that the patient is a suitable candidate for SNS (capable of operating device, lacks exclusionary neurologic disease or mechanical outlet obstruction).
Documentation of preoperative counseling must be included with authorization request (risks, benefits, alternatives, device management).
For screening trials (percutaneous nerve evaluation or Stage I lead), the medical record must document test-phase success: ≥50% improvement in one or more troublesome urinary or bowel parameters or, for urinary frequency, return to <8 voids/day. For chronic urinary retention, PVR and duration documentation must meet defined thresholds.
Follow-up requirement: post-implantation follow-up evaluation and device programming/management notes should be available in the medical record and may be requested for ongoing coverage review.
Provider Actions, Prior Authorization, and Documentation
Prior Authorization
Require documented test-phase success and indication support
Prior authorization determinations should include documentation that the patient achieved a successful test-phase response, commonly defined as ≥50% improvement (or return to <8 voids/day) during the screening trial, and that the indication-specific evidence supports likely benefit.
Successful test stimulation commonly defined as ≥50% improvement in urinary incontinence or frequency or return to <8 voids/day
Consider pooled test and permanent success rates from meta-analyses when assessing likelihood of benefit
Prior Authorization
Prior authorization must confirm failed conservative/medical therapy
Prior authorization requests must confirm the patient had an inadequate response or intolerance to appropriate conservative and medical therapies and that all coverage criteria for SNS are met before approving permanent implantation.
Confirm failure or intolerance of behavioral and pharmacologic therapies prior to considering SNS
Verify patient is an appropriate surgical candidate and able to operate the device
Background and Rationale
Sacral Nerve Stimulation places an electrode tip near the sacral nerve to modulate voiding and pelvic floor function. It is used as a third-line therapy for select patients with overactive bladder, urge incontinence, and nonobstructive urinary retention, and for fecal incontinence; candidates typically undergo a temporary screening trial (PNE or staged testing) and are considered for permanent implantation only if the trial demonstrates adequate response.
Definitions and Key Terms
inv-50: Chronic Urinary Retention — Postvoid residual volume (PVR) ≥ 300 mL persisting for ≥ 6 months and documented on ≥ 2 separate occasions.
DefinitionChronic Urinary Retention: postvoid residual volume (PVR) ≥ 300 mL persisting for ≥ 6 months
DocumentationRequires PVR documented on ≥ 2 separate occasions
Source referenceDiagnostic threshold cited to Stoffel et al., 2016 within policy definitions
inv-51: Chronic Pelvic Pain — Persistent or recurrent episodic pelvic pain associated with lower urinary, sexual, bowel, or gynecological symptoms with no proven infection.
DefinitionChronic Pelvic Pain: persistent or recurrent episodic pelvic pain associated with lower urinary, sexual, bowel, or gynecological symptoms with no proven infection or other obvious pathology
Clinical context
Policy Summary
PayerUnitedHealthcare
PolicySacral Nerve Stimulation for Urinary and Fecal Indications (for North Carolina Only)
Policy CodePolicy CSNCT0358.02
Change TypeDocumentation and coding clarificationsminor wording and reference updates
Effective DateDecember 1, 2025
Next Review DateN/A
Key ActionEnsure medical records fully document history, physical exam, and diagnostic test results to support medical necessity and prior authorization decisions.
Heterogeneity and risk of bias in underlying studies
Fecal incontinence / LARS: Randomized and observational studies support SNM for fecal incontinence and LARS with long-term improvements in objective and quality-of-life measures; reported long-term revision rate ~35% and explant rate ~19.7%
Heterogeneity and lack of comparative trials limit strength of evidence
Chronic pelvic pain (CPP): Evidence is insufficient or mixed; systematic reviews report pain reduction in many case series but a lack of high-quality RCTs; SNM considered investigational/uncertain for many CPP etiologies pending higher-quality trials
Further high-quality randomized studies required
Chronic pelvic pain (CPP) and IC/BPS:
Evidence indicates SNM may improve pain and urinary symptoms in some CPP populations and IC/BPS, but overall evidence is limited and variable; consider SNM only after careful assessment and when refractory to conservative therapies, recognizing lower strength of evidence for IC/BPS and non-IC/BPS CPP.
refractory to conservative therapies
Systematic reviews report modest benefits for non-BPS CPP etiologies and limited evidence for BPS/IC (Mahran 2019; Tutolo 2018; ICS statement).
Constipation / slow transit constipation (STC): Evidence is insufficient to support routine use of SNM for chronic constipation/STC; randomized trials show conflicting results and meta-analyses find inconclusive effectiveness and safety, so SNM should not be routinely used for constipation outside of research or selected cases.insufficient high-quality evidence
Heemskerk 2024 showed short-term benefit vs conservative treatment but other RCTs and systematic reviews found no consistent benefit; ACG/other guideline statements do not support SNS for constipation.
Neurogenic lower urinary tract dysfunction (nLUTD) and neurogenic OAB: Evidence is mixed; some reviews and series suggest SNM can be effective and safe in carefully selected individuals with neurogenic bladder (including MS) and lower risk of upper tract deterioration, with maintained efficacy in a subset long-term; consider SNM in carefully selected neurogenic patients refractory to conservative therapy.careful selection and refractory to conservative therapy
Systematic reviews and cohort data suggest improvements in frequency, incontinence episodes, voided volume, and PVR for neurogenic populations, but overall evidence quality varies.
failed conservative therapy
ICS and ASCRS support SNM as second-line or first-line surgical option depending on guideline
Constipation (chronic) and other indications: SNM may be considered for chronic constipation after failed conservative measures, but evidence is limited and FDA approval is not established for constipation in the USfailed conservative therapy
ASCRS notes insufficient high-quality evidence and lack of FDA approval for constipation
Step therapy sequencing: SNS is considered after failure of appropriate conservative and medical therapies; permanent implantation is contingent upon documented successful screening trial.
Codes listed are for reference and may require prior authorization; presence of a code does not guarantee coverage.
Note
Code list for referenced SNS procedures and devices — Prior authorization applicable
CPT procedure codes and HCPCS device codes related to sacral nerve stimulation are provided for reference. Codes marked with an asterisk are noted as not being on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by NC Medicaid. Inclusion of codes is for reference and does not imply coverage or reimbursement.
Prior authorization applies to procedures and devices listed; include code(s) on request for specificity.
Documentation Required
Key Clinical Thresholds and Documentation
Minimum documented clinical thresholds to support prior authorization and implantation decisions: bladder capacity ≥ 100 mL; chronic urinary retention defined as PVR ≥ 300 mL documented on ≥2 occasions over ≥6 months; screening trial response defined as ≥50% improvement in reported symptoms (or <8 voids/day where applicable).
Document baseline symptom severity and objective measures (voiding diary, PVR, urodynamics if performed).
Document that symptoms are not due to neurologic disease or mechanical outlet obstruction and that conservative therapies were tried and failed unless contraindicated.
Referenced CPT/Procedure 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.
Referenced HCPCS/Device CodesHCPCS
L8679
Implantable neurostimulator, pulse generator, any type.
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.
Sample ICD-10 CodesICD-10
N32.81
Overactive bladder.
N39.3
Stress incontinence.
N39.41
Urge incontinence.
N39.42
Incontinence without sensory awareness.
N39.46
Mixed incontinence.
N39.490
Overflow incontinence.
R32
Unspecified urinary incontinence.
R33.0
Drug induced retention of urine.
R33.8
Other retention of urine.
R35.0
Frequency of micturition.
1–10 of 13
1/2
Prior Authorization
Specialist review and documentation of prior conservative therapy
Document multidisciplinary/specialist review and prior failed conservative/medical therapies as part of the prior authorization submission; NICE recommends specialist unit patient selection before offering SNM.
Document MDT or specialist review where applicable
Record prior conservative therapy attempts (and BTX consideration where relevant)
Billing Rule
Prior authorization and coding note (external tool use and NC fee schedule)
Prior authorization and benefit review may require application of standard plan criteria and external tools; note certain CPT/HCPCS device and lead codes may require additional review and some codes are not on the NC Medicaid fee schedule.
UnitedHealthcare may use third‑party tools (e.g., InterQual) to assist in benefit administration
Codes noted (e.g., 0784T–0787T and L8679–L8688) may not be covered by NC Medicaid
Step Therapy
Conservative therapies must be tried and failed
Ensure documentation shows trials of conservative therapies (e.g., bladder/bowel training, pelvic floor rehabilitation, pharmacologic therapy) and that symptoms remained refractory before progressing to SNM.
Conservative measures such as bladder training, pelvic floor rehab, and medication must have been tried and proven ineffective
For fecal indications, include trials of bowel training and bulking agents
Step Therapy
SNM/PTNS are third-line therapies after failed behavioral and medical therapy
SNM and PTNS are considered third-line treatments for OAB after failure of behavioral and pharmacologic therapies; prior authorization may require documentation of failed second-line therapies.
Document failures of behavioral and pharmacologic therapy before SNM or PTNS
SNM may be considered when patients are not suitable for or have failed other second-line options (e.g., BTX)
Step Therapy
Document prior stepwise therapies before authorizing SNS
Sequence prior therapies in the record: demonstrate stepwise failure or intolerance of behavioral then medical therapies before SNM is authorized as a third-line option.
Document stepwise treatment history (behavioral → pharmacologic → third-line SNM)
Confirm patient suitability for surgical implantation and device self-management
Step Therapy
SNM considered after failed conservative/medical therapy and MDT review
Before approving SNM, document that conservative and medical therapies were tried and that MDT/specialist review occurred; for some patients, botulinum toxin should have been considered or reasonably declined.
Evidence of failed conservative and medical therapies for OAB/UUI
Record MDT review and whether BTX was tried, contraindicated, or declined
Note
Use of external criteria/tools (e.g., InterQual) may be applied
UnitedHealthcare may apply external clinical criteria tools (such as InterQual) to assist in administering benefits, which can include prior authorization and step‑therapy checks.
Third‑party criteria may be used to standardize reviews and authorizations
Check plan-specific contractual requirements in addition to policy guidance
Documentation Required
Medical record documentation must fully support medical necessity
Medical records submitted for prior authorization and review must include relevant medical history, physical exam findings, diagnostic test results, and legible documentation that supports medical necessity for the requested SNS service.
Include history, physical examination, and pertinent diagnostic test/procedure results
Ensure documentation is legible and available upon request
Document test-phase (screening trial) success using voiding diaries or validated measures showing commonly accepted thresholds (≥50% improvement or return to <8 voids/day) before proceeding to permanent implantation.
Successful test stimulation commonly defined as ≥50% improvement in UI or urinary frequency or return to <8 voids/day
Use voiding diaries and symptom questionnaires to support measured improvement
Documentation Required
Document prior conservative/medical therapy and candidate suitability
Prior authorization records should explicitly show prior trials of conservative/medical therapy (e.g., antimuscarinics, beta‑3 agonists, behavioral therapy) and evidence the patient is a suitable candidate for implantation.
List specific prior medications and non‑drug interventions tried and durations
Confirm cognitive ability to operate device and willingness for long‑term follow‑up
Documentation Required
Preoperative counseling and risks must be documented
Document preoperative counseling that covers lifelong follow‑up, battery replacement, risk of implant site pain, infection, paresthesia, need for reprogramming or revision, and provide written patient information.
Record discussion of long‑term surveillance and battery replacement needs
Document risks: implant site pain, infection, paresthesia, leg pain, and potential need for reprogramming or revision
Documentation Required
Medical records must fully support medical necessity and be available on request
The patient's medical record must contain complete and legible documentation that supports medical necessity for the requested services, including history, exam, and pertinent diagnostic results; records must be made available upon request.
Ensure documentation is maintained in the medical record and is legible
Make supporting records available when requested for review
Denial Risk
Denial triggers for urinary indications — common exclusions
Requests may be denied if coverage criteria are not met, including patient age under 18, bladder capacity <100 mL, urinary dysfunction secondary to neurologic disease, presence of bladder outlet or mechanical obstruction, lack of trial of conservative care, or inability to operate the device.
Age must be ≥18 years
Bladder capacity must be ≥100 mL
Urinary dysfunction must not be secondary to neurologic disease or mechanical obstruction
Documented failure of conservative care and ability to operate device required
Denial Risk
Denial risk if screening trial improvement <50% or trial criteria not met
Permanent implantation may be denied if documented improvement during the screening trial is less than 50% or if screening trial criteria were not met and documented.
Screening trial improvement must be ≥50% to support permanent implantation
If trial criteria or documentation are inadequate, permanent implantation may be denied
Denial Risk
Test‑phase response required for chronic refractory NOUR candidates
Individuals with chronic refractory neurogenic non‑obstructive urinary retention often have inadequate responses during initial testing and may not be candidates for SNS; insufficient test‑phase response can trigger denial of permanent implantation.
Chronic refractory NOUR patients frequently are not candidates due to inadequate initial test response
Use trial results to determine candidacy for permanent SNS
Documentation Required
Document plan for lifelong follow‑up and surveillance after implant
Life‑long surveillance after SNS implantation is recommended to monitor for lead displacement, device malfunction, and battery depletion; lack of appropriate follow‑up may affect ongoing authorization or device management.
Document plans for lifelong follow‑up and monitoring
Monitor for lead migration, malfunction, and need for battery replacement
Denial Risk
Failed therapeutic trial is an absolute contraindication to implantation
Insufficient clinical response to the therapeutic trial is an absolute contraindication to permanent implantation and will preclude approval for permanent device placement.
If trial stimulation does not produce adequate clinical response, do not proceed to permanent implantation
Incapacity to operate device without caregivers is also an absolute contraindication
Billing Rule
NC Medicaid fee schedule exclusion risk for listed CPT/HCPCS codes
Certain CPT and HCPCS codes (0784T, 0785T, 0786T, 0787T, L8679, L8680, L8682, L8685, L8686, L8687, L8688) are not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by NC Medicaid—verify NC Medicaid coverage prior to billing.
Codes flagged in policy as not on NC Medicaid Fee Schedule: 0784T, 0785T, 0786T, 0787T, L8679, L8680, L8682, L8685, L8686, L8687, L8688
Inclusion in policy does not guarantee coverage—confirm state fee schedule before submitting claims
CPP may be associated with pelvic floor dysfunction; evidence for SNS in CPP is limited and mixed
ReferenceDefinition cited to Fall et al., 2010 in policy definitions
inv-52: Sacral Nerve Stimulation (SNS) — Implantation of an electrode tip near the sacral nerve to stimulate nerves controlling lower urinary function; also known as sacral neuromodulation.
DefinitionSacral Nerve Stimulation (SNS): implantation of an electrode tip near the sacral nerve to stimulate nerves controlling lower urinary function (also known as sacral neuromodulation)
MechanismActs as a pacemaker for the bladder by stimulating afferent fibers to improve urinary function
IndicationsUsed for OAB, urge incontinence, non-obstructive urinary retention and being explored for other pelvic disorders
inv-53: Successful test stimulation — Commonly defined as ≥50% improvement in urinary incontinence or urinary frequency symptoms or return to normal voiding (<8 voids/day) during the trial period.
Successful test stimulationCommonly defined as ≥50% improvement in urinary incontinence or urinary frequency symptoms or return to normal voiding (<8 voids/day) during the trial period
MeasurementSuccess documented in voiding diaries, questionnaires, and clinical evaluation during PNE/Stage 1
ImplicationA successful trial (per this definition) is required before permanent implantation is considered
inv-54: Major clinical endpoints (fecal) — Reduction in validated scores such as LARS score, St. Mark's continence score, and improvement in bowel diaries and QoL instruments.
Major endpoints (fecal)Reduction in validated scores such as LARS score and St. Mark's continence score, plus improvement in bowel diaries and quality-of-life instruments
Trial success criteria (example)In LARS trial, a 50% reduction in LARS score during advanced test phase was used to proceed to implant
Outcome measuresContinence scores, bowel symptom frequency, urgency, clustering, and QoL assessed at 6–12 months
inv-55: Trial phase / percutaneous nerve evaluation (PNE) — A temporary stimulation trial (PNE or staged test) used to predict therapeutic success of permanent SNM implantation; the trial phase is described in the policy.
DefinitionTrial phase / percutaneous nerve evaluation (PNE): a temporary stimulation trial (PNE or staged test) used to predict therapeutic success of permanent SNM implantation
Predictive valueThe trial phase is considered the most valued tool for predicting potential therapeutic success for urinary indications
Use caseUsed to determine candidacy for permanent implantation across urinary and fecal indications
inv-56: Percutaneous Nerve Evaluation (PNE) / Stage 1 test stimulation — Temporary test stimulation phase used to screen patients for likely benefit from permanent SNM; PNE typically lasts ~7 days for bladder and 10-21 days for bowel.
DefinitionPercutaneous Nerve Evaluation (PNE) / Stage 1 test stimulation: temporary test stimulation phase used to screen patients for likely benefit from permanent SNM
Typical durationsPNE typically lasts ~7 days for bladder indications and 10–21 days for bowel indications; Stage 1 testing typically lasts 2–3 weeks
Repeat testingStage 1 testing may be repeated at clinician's discretion if PNE is questionable
inv-57: Sacral Nerve Stimulation (SNS) / Sacral Neuromodulation (SNM) — Policy added a definition indicating SNS is also known as sacral neuromodulation or urologic nerve stimulation.
TerminologySacral Nerve Stimulation (SNS) / Sacral Neuromodulation (SNM): policy indicates SNS is also known as sacral neuromodulation or urologic nerve stimulation
Mechanism summarySmall electrode near sacral nerve provides neuromodulation to improve urinary function
Clinical scopeUsed for OAB, UUI, NOUR, and fecal incontinence; under investigation for other pelvic conditions