ModifiedUnitedHealthcarePolicy CS358OH.E

Sacral Nerve Stimulation for Urinary and Fecal Indications (for Ohio Only)

This policy governs coverage and medical necessity criteria for sacral nerve stimulation (SNS/SNM) for urinary and fecal indications for individuals in Ohio aged 18 years and older.

Policy Summary

PayerUnitedHealthcare

PolicySacral Nerve Stimulation for Urinary and Fecal Indications (for Ohio Only)

Policy CodePolicy CS358OH.E

Change TypeTerminology, documentation, and reference updates

Effective DateJan 1, 2026

Next Review Date

Key ActionObtain prior authorization and document ≥50% improvement during a PNE or Stage 1 test before proceeding to permanent implantation.

SourceLink

POLICY UPDATE CHANGES

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

Added language that medical records documentation may be required to assess whether the member meets clinical criteria for coverage and that documentation must support medical necessity.

Added 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.

Updated related policy link for Gastrointestinal Disorders Diagnostic Procedures (Ohio only).

≥18age floor

≥100 mLmin bladder capacity

≥50%trial improvement threshold

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3–7 daystypical PNE duration

2-3 weeksStage 1 duration

CS358OH.Darchived prior version

Coverage Criteria for Sacral Nerve Stimulation

SNS screening trial — urinary

Covered when ALL of the following are met:

Urinary screening trial criteria: Lower urinary tract symptoms (overactive bladder symptoms, urge incontinence, or nonobstructive urinary retention)

Bladder capacity of 100 ml or greater>= 100 mL

Neurologic origin exclusion: Urinary voiding dysfunction is not secondary to a neurologic disease origin (e.g., Parkinson's disease, stroke, spinal cord injury, multiple sclerosis)

Obstruction exclusion: No bladder outlet or mechanical obstruction (e.g., BPH, tumor/radiation obstruction, urethral stricture)

Conservative therapy failure: Symptoms refractory to conservative care (e.g., bladder training, pelvic floor rehabilitation, pharmacological therapy)

Device operation capability: Individual capable of operating sacral nerve stimulating device

SNS permanent implantation — urinary

Covered when ALL of the following are met:

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

Screening trial response: Improvement in reported symptoms of 50% or greater in response to a screening trial of sacral nerve stimulation>= 50%

SNS screening trial — fecal

Covered when ALL of the following are met:

Fecal symptoms refractory: Symptoms refractory to conservative care (e.g., bowel training, bulking agents, pelvic floor rehabilitation, pharmacological therapy)

Device operation capability: Individual capable of operating sacral nerve stimulating device

Neurologic origin exclusion: Fecal Incontinence is not secondary to a neurologic disease origin (e.g., Parkinson's disease, stroke, spinal cord injury, multiple sclerosis)

Constipation exclusion: Fecal Incontinence is not secondary to Constipation

Anatomic exclusion:

SNS permanent implantation — fecal

Covered when ALL of the following are met:

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

Screening trial response: Improvement in reported symptoms of 50% or greater in response to a screening trial of sacral nerve stimulation>= 50%

Replacement or revision

Replacement/revision: Replacement or revision of sacral nerve stimulator is medically necessary when the individual has met all above criteria and the existing device is nonfunctional and cannot be repaired or is no longer under warranty

Unproven indications

Constipation and Chronic Pelvic Pain: SNS for treatment of Constipation and Chronic Pelvic Pain is unproven and not medically necessary due to insufficient evidence of safety and/or efficacy

Eligibility and success criteria used in literature

Coverage-relevant clinical criteria commonly present in the literature:

Typical trial inclusion: Patient has refractory OAB or refractory urinary/fecal symptoms after trying and failing conservative treatments (behavioral and pharmacologic)

These elements reflect inclusion criteria used across multiple RCTs and observational studies.

Demonstrated successful test stimulation: Demonstrated a successful test stimulation commonly defined as ≥50% symptom improvement on diaries or validated scores>= 50%

Successful test stimulation definitions and rates reported across trials and meta-analyses.

Absence of contraindicating conditions (e.g., active urinary tract infection, uncontrolled diabetes, recent botulinum toxin within trial-specified exclusion windows)

Exclusion criteria varied by trial; clinical trial exclusions commonly included neurologic conditions and infection.

Guideline- and evidence-aligned coverage criteria

Covered when criteria match guideline-supported indications and conservative therapies have failed

OAB/UUI (non-neurogenic): Offer SNM for OAB/UUI refractory to conservative and medical therapy in patients willing to undergo surgery; long-term surveillance required for implanted patients.failure of conservative/pharmacologic therapy (guideline references suggest ≥3 months or as clinically appropriate)

AUA/SUFU and EAU recommend SNM as third-line; expect counseling about adverse events and device maintenance.

Fecal Incontinence (FI): Consider SNM for bothersome FI after failed conservative measures; anal sphincter defect is not an absolute contraindication.failed conservative therapy

ICS and ASCRS guidance support SNM for FI; anal sphincteroplasty considered when anatomic defect present.

Low Anterior Resection Syndrome (LARS):

Initial therapy (per professional guidance)

Covered when ALL of the following are met (per ICS, NICE, ASCRS guidance):

Primary indication and prior therapy: Individual has refractory symptoms (OAB, UUI, NOUR, or FI) that have failed conservative and medical therapies and, where applicable, MDT review has been completed

Supported by ICS, NICE, and ASCRS recommendations

Trial stimulation response: Patient achieved >=50% improvement in one or more target urinary or bowel parameters during PNE or Stage 1 test period>=50% improvement

PNE typically 7 days bladder / 10-21 days bowel; Stage 1 typically 2-3 weeks

Informed consent and counseling: Preoperative counseling documented about risks, need for potential revisions, battery replacement, MRI considerations, and long-term commitment

NICE and ICS emphasize providing written information and discussion of long-term implications

Sacral Nerve Stimulation (neurostimulation) is not covered when the presenting urinary or fecal dysfunction is secondary to a neurologic disease. Examples listed in the policy include Parkinson's disease, stroke, spinal cord injury, and multiple sclerosis (MS). For urinary indications the criteria explicitly require that the urinary voiding dysfunction is not secondary to a neurologic disease origin, and for fecal indications the policy similarly excludes fecal incontinence when it is secondary to neurologic disease. In addition, urinary coverage requires no bladder outlet or mechanical obstruction (for example, BPH, tumor- or radiation-related obstruction, or urethral stricture) and fecal eligibility excludes cases where symptoms are secondary to Constipation or where there is distorted anorectal anatomy (e.g., anorectal malformation, abscess/fistula, prior rectal surgery).

Randomized controlled trials have applied additional exclusion criteria when enrolling participants. Representative RCT exclusions cited include patients with neurological conditions, uncontrolled diabetes, active urinary tract infection, stress incontinence, or recent treatment with botulinum toxin (Botox) within specified washout windows. These trial-based exclusions inform selection and may be considered during prior authorization review.

The policy states that evidence is insufficient to support routine coverage of SNM for constipation. Multiple systematic reviews and randomized trials have produced conflicting or negative results: some RCTs and meta-analyses showed no significant benefit versus sham or conservative treatment, and published reviews concluded the evidence is inconclusive regarding efficacy, safety, and cost-effectiveness for refractory idiopathic slow transit constipation.

The document lists absolute contraindications that preclude coverage. These include insufficient clinical response to a therapeutic trial, inability of the patient to operate the device without supportive caregivers, and pregnancy.

When applying this policy, reviewers and providers must also reference applicable federal, state (Ohio Administrative Code), or contractual benefit requirements, since those rules may differ from the standard benefit plan and govern in cases of conflict. The policy notes that medical record documentation may be required to assess whether the member meets clinical criteria for coverage but does not itself guarantee coverage.

UnitedHealthcare considers SNS for Constipation and Chronic Pelvic Pain to be unproven and not medically necessary because available studies do not provide sufficient evidence of safety and efficacy for these indications.

Specifically for chronic pelvic pain, the policy highlights that there is insufficient evidence to support SNM and that higher-quality, well-controlled studies are required before routine use can be recommended for CPP.

Some randomized trials and systematic reviews cited in the policy did not demonstrate a clear benefit of active SNM versus sham stimulation for refractory constipation; as a result, the policy indicates that permanent implantation after temporary responder testing is not supported by these trials for routine practice absent stronger evidence.

Relative contraindications are noted that may necessitate individualized review or lead to noncoverage. These include severe or rapidly progressive neurologic disease, established complete spinal cord injury, anticipated need for MRI of body parts below the head, and abnormal sacral anatomy.

Within the excerpt provided there are no additional explicit listings of 'Not Medically Necessary' conditions beyond those already described; the policy reiterates that federal, state, or contractual benefit rules may specify further limitations and that documentation must support medical necessity for requested services.

Billing and 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/Device 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.

Fecal Indications (ICD-10)ICD-10

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

Urinary Indications (ICD-10)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.

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inv-24: SNS screening trial improvement — ≥ 50% improvement in reported symptoms

Screening trial improvement threshold>= 50% improvement in reported urinary symptoms during screening trial

Typical screening trial duration3–7 days (initial trial period) as commonly used in trials

Purpose of thresholdUsed to determine eligibility for permanent neurostimulator implantation after observed symptomatic response

inv-25: Chronic Urinary Retention PVR — ≥ 300 mL

PVR thresholdPostvoid residual volume (PVR) ≥ 300 mL

Duration requirement

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required for Third-Line Neuromodulation

Prior authorization is required for third-line neuromodulation procedures (e.g., percutaneous tibial nerve stimulation [PTNS], sacral nerve modulation/stimulation [SNM/SNS]) when used as third-line therapy after failure of conservative and pharmacologic treatments. UnitedHealthcare expects prior authorization for placement, revision, removal, and implantable neurostimulator devices represented by the applicable CPT/HCPCS codes.

Prior authorization required for placement, revision, removal, and implantable neurostimulator devices (see applicable CPT/HCPCS lists).
PTNS and SNM are positioned as third-line options after failure of behavioral and pharmacologic therapy; SNM may be considered second-line for fecal incontinence after conservative therapy failure.

Prior Authorization

Prior Authorization Expectation for Sacral Nerve Modulation (SNM)

Prior authorization is expected for sacral nerve modulation (SNM/SNS) when indicated for refractory overactive bladder (OAB)/urge urinary incontinence (UUI), selected underactive bladder (UAB), and functional bladder outlet obstruction (after failed conservative therapy). Authorization decisions will require documentation that conservative therapies and medical therapy have been tried and failed.

Background and Evidence Summary

Sacral Nerve Stimulation (SNS), also described as sacral neuromodulation, places an electrode near sacral nerves (commonly S3) to modulate afferent signaling and improve bladder and pelvic floor function. The policy explains that SNS is used for disorders such as overactive bladder, urge urinary incontinence, nonobstructive urinary retention, and fecal incontinence, and that a screening test period (e.g., PNE or Stage 1) is used to identify responders prior to offering permanent implantation.

Key Definitions

inv-52: Chronic Urinary Retention — PVR ≥ 300 mL persisting ≥ 6 months, documented on ≥ 2 occasions

Core definitionChronic Urinary Retention: PVR ≥ 300 mL persisting for ≥ 6 months

Verification requirementDocumented on ≥ 2 separate occasions

Reference guideline/sourceDefinition cited from Stoffel et al., 2016 in policy definitions

inv-53: Fecal Incontinence — definition of FI and severity range

DefinitionFecal Incontinence: involuntary passage of fecal matter or inability to control discharge of bowel contents

Severity rangeSeverity ranges from involuntary passage of flatus to complete evacuation of fecal matter

Policy Revision History

2026-04-01revision

Updated related policy link to Gastrointestinal Disorders Diagnostic Procedures (for Ohio only).

2026-01-01revisionLatest

Replaced references to 'Sacral Nerve Stimulation' with 'Sacral Nerve Stimulation (neurostimulation)' and added medical records documentation language specifying that documentation may be required to assess clinical criteria and must support medical necessity.

(archived)archival

Previous policy version CS358OH.D. archived when supporting information, FDA, and references were updated.

Policy Summary

PayerUnitedHealthcare

PolicySacral Nerve Stimulation for Urinary and Fecal Indications (for Ohio Only)

Policy CodePolicy CS358OH.E

Change TypeTerminology, documentation, and reference updates

Effective DateJan 1, 2026

Next Review Date

Key ActionObtain prior authorization and document ≥50% improvement during a PNE or Stage 1 test before proceeding to permanent implantation.

SourceLink

On This Page

Lack of distorted anatomy (e.g., anorectal malformation, abscess or fistula, rectal surgery)

Outcomes used to define success: Reduction in UI episodes/day, reduction in micturition frequency, improvement in validated QoL questionnaires (e.g., ICIQ-OABqol, PGI-I, St. Mark's), or ≥50% reduction in condition-specific scores (e.g., LARS)

Trials reported outcomes at typical follow-up times (e.g., 12 weeks to 2 years)

SNM may be offered for LARS with demonstrated response to PNE and after conservative therapy; high rates of PNE response and clinical success reported.

successful PNE/percutaneous nerve evaluation

Meta-analysis reported high PNE response and strong post-implant success rates.

Constipation (idiopathic STC): Evidence is insufficient; SNS may be considered in select refractory idiopathic slow transit constipation after ≥1 year of symptoms and failed conservative therapy but overall recommendations caution due to inconsistent RCT results.>1 year symptoms and failed conservative therapy

Systematic reviews and RCTs show conflicting results; guideline groups advise caution.

Neurogenic bladder / urinary voiding dysfunction secondary to neurologic disease: Evidence is mixed; SNM may be feasible in carefully selected individuals with neurogenic lower urinary tract dysfunction refractory to conservative treatments and motivated to minimize catheterization; outcomes may be similar to non-neurogenic patients in select studies.refractory to conservative measures and careful selection

Some systematic reviews and cohort studies report improvements but overall evidence quality limited.

Device-specific regulatory status: Device used has appropriate regulatory clearance or approval (FDA approvals cited for InterStim, Axonics r-SNM, Neuspera PMA noted) — informational for device selection

FDA approvals summarized; FDA info is informational only

Persists for ≥ 6 months

Documentation frequencyDocumented on ≥ 2 separate occasions

inv-26: Test-phase improvement threshold — >= 50% improvement in one or more troublesome urinary or bowel parameters

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

Outcome measures consideredVoiding diaries, reduction in UI episodes, validated QoL or symptom scores (e.g., ICIQ-OABqol, PGI-I)

Use for permanent implant decisionThreshold used as criterion to offer complete system implantation after test phase

inv-27: PNE test stimulation period (bladder / bowel) — 7 days / 10-21 days

PNE bladder test durationTypically 7 days for bladder indications

PNE bowel test durationTypically 10–21 days for bowel indications

Intent of PNE periodShort percutaneous screening to predict likelihood of success with permanent SNM

inv-28: Stage 1 test period duration — 2-3 weeks

Stage 1 test durationTypically 2–3 weeks for implant-based test period

When usedUsed when PNE is questionable or a longer screening period is desired

Repeat testingStage 1 testing may be repeated at physician's discretion

SNM indicated for refractory OAB/UUI and selected UAB/functional BOO after failed conservative therapy.
Authorization requires evidence of prior conservative and medical therapy failure (see documentation requirements).

Documentation Required

Medical Record Documentation Requirements

Medical records must fully support the medical necessity of the requested service. Lack of required documentation or documentation that does not substantiate the clinical criteria may result in denial.

Medical history, physical exam, and pertinent diagnostic test/procedure results must be present and legible.
Records must be available upon request; absence or illegibility is a common trigger for denial.

Documentation Required