ModifiedUnitedHealthcarePolicy CS358TN.E

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

Medical policy governing sacral nerve stimulation (SNS/SNM) for urinary and fecal indications for Tennessee Medicaid and CoverKids beneficiaries aged 18 and older; covers screening trial, permanent implantation, revisions/replacements, and exclusions.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS358TN.E

Change TypeModified — documentation and references updated

Effective DateDec 1, 2025

Next Review Date

Key ActionObtain and retain legible medical records documenting test-phase success (≥50% improvement) and prior conservative therapy to support prior authorization and coverage.

SourceLink

POLICY UPDATE CHANGES

Added language clarifying that medical records documentation may be required to assess whether the member meets clinical criteria and listing examples of required documentation.

Updated reference link to reflect the current policy title for Gastrointestinal Disorders Diagnostic Procedures (for Tennessee Only).

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

Updated Clinical Evidence, FDA, and References sections to reflect the most current information and archived a previous policy version.

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

≥18min age

50%trial success req

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Coverage Criteria for Sacral Nerve Stimulation

SNS screening trial for urinary voiding dysfunction

Covered when ALL of the following are met

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

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)

No mechanical obstruction: No bladder outlet or mechanical obstruction (e.g., BPH, obstruction from tumor or prior radiation, urethral stricture)

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

Patient capability: Individual capable of operating sacral nerve stimulating device

Permanent SNS implantation for urinary voiding dysfunction

Covered when ALL of the following are met

Trial criteria: 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% improvement

SNS screening trial for fecal incontinence

Covered when ALL of the following are met

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

Patient 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:

Permanent SNS implantation for fecal incontinence

Covered when ALL of the following are met

Trial criteria: 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% improvement

Replacement or revision of SNS device

Previous criteria met: Individual has met all above criteria for original therapy

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

Coverage criteria for permanent SNM

Covered when ALL of the following are met

Test phase response: Patient demonstrates a successful test stimulation (commonly defined as ≥50% improvement in target symptoms or return to normative voiding), documented by voiding diaries or relevant disease-specific scores≥50% improvement

Supported by trial definitions and meta-analyses

Indications: Indication includes refractory overactive bladder (OAB)/urge urinary incontinence, non-neurogenic or neurogenic LUTD with demonstrated benefit, fecal incontinence including LARS after failed conservative therapy, or chronic pelvic pain where evidence suggests benefit

Indications reflected across systematic reviews and trials

Prior therapies: Failure of or intolerance to first-line behavioral and pharmacologic therapies (for OAB) and, where applicable, prior standard conservative measures for fecal incontinence/LARS

SNM described as third-line or for refractory cases

Indications supported by guidelines and evidence

Covered when guideline-supported clinical indications and prior conservative therapy requirements are met as described below.

Overactive bladder (OAB)/Urgency Urinary Incontinence (UUI): Offer SNM for patients with OAB/UUI who have inadequate response to or intolerable side effects from pharmacotherapy and behavioral therapy; SNM may be offered as third-line therapy in carefully selected patients willing to undergo surgery.after failure of conservative/pharmacologic/behavioral therapy

AUA/SUFU and EAU recommend offering SNM; ICS supports offering SNM for refractory OAB (Level I/A).

Fecal incontinence (FI): Consider SNM for individuals with moderate or severe FI not responding after at least three months of conservative measures including biofeedback, provided no contraindications exist.failure of conservative measures >= 3 months

ACG and AGA recommendations support SNM for FI after conservative therapy failure.

Chronic pelvic pain (CPP) and interstitial cystitis/bladder pain syndrome (IC/BPS):

Eligibility and testing criteria for SNM

SNM may be offered when specified conditions are met according to international guidance:

Refractory OAB/UUI (EAU, ICS, NICE): Offer SNM to individuals with OAB/UUI refractory to conservative/medical therapy or when botulinum toxin is ineffective or unacceptable.refractory to conservative/medical therapy

EAU strong recommendation based on moderate-quality evidence; ICS Level I/A; NICE recommends after MDT review and failure of non-surgical management.

Trial stimulation success: Individual achieves >=50% improvement in one or more troublesome urinary or bowel parameters during PNE or Stage 1 test.>=50% improvement

PNE typical duration 7 days (bladder) or 10-21 days (bowel); Stage 1 typically 2-3 weeks.

Device candidacy exclusions: Exclude individuals with insufficient clinical response to therapeutic trial, inability to operate device without caregivers, or pregnancy; consider risks in severe neurologic disease, complete SCI, expected need for MRI below head, or abnormal sacral anatomy.

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. The policy cites randomized trials and systematic reviews that show conflicting results, heterogeneity in study populations and methods, and concerns about long-term effectiveness, adverse events, and cost-effectiveness, supporting a determination that routine coverage is not indicated for these indications.

Patients with chronic refractory non-obstructive urinary retention (NOUR) are frequently not candidates for permanent SNS because of inadequate response during initial testing. Evidence assessments note that SNS may improve outcomes for selected individuals with intractable NOUR who fail standard therapies, but careful patient selection and a successful test-phase response are essential before considering permanent implantation.

The evidence base for SNS to treat constipation is insufficient and inconsistent. Multiple systematic reviews and randomized trials show heterogeneous populations and conflicting results, including double-blinded cross-over RCTs reporting no significant benefit over sham and at least one randomized cross-over study that found no clear advantage of active stimulation. Limitations cited include small sample sizes, variable definitions of refractory disease, short follow-up in some trials, and inconsistent reporting of adverse events and cost-effectiveness.

Pregnancy is listed as an absolute contraindication to sacral nerve stimulation. The policy explicitly identifies pregnant individuals among absolute contraindications alongside insufficient clinical response to a therapeutic trial and inability to operate the device without caregiver support.

Policy history notes recent revisions including updated terminology to 'Sacral Nerve Stimulation (neurostimulation),' additions clarifying that medical records documentation may be required to assess clinical criteria, and updates to Supporting Information (Clinical Evidence, FDA, and References). The excerpt does not list any additional explicit exclusions beyond those described in the coverage rationale and contraindications sections.

Treatment of Constipation and Chronic Pelvic Pain with sacral nerve stimulation is considered not medically necessary (unproven). The policy references systematic reviews and randomized trials for constipation and a 2024 systematic review for chronic pelvic pain that conclude current evidence is inadequate to support routine use and that higher-quality studies are needed to establish efficacy and safety.

Use of SNS for chronic pelvic pain is insufficiently supported by high-quality evidence. A recent systematic review identified few randomized trials and many case series with heterogeneous patient populations; authors concluded that neuromodulation is a developing approach for chronic pelvic pain syndromes but that further studies of homogeneous populations and higher-quality randomized evidence are required before strong recommendations can be made.

Permanent sacral neuromodulation for refractory constipation is not supported by conclusive evidence. Randomized and double-blinded cross-over trials have produced conflicting or negative results versus sham stimulation, and systematic reviews have concluded that evidence on effectiveness, safety, and cost-effectiveness is insufficient to recommend routine permanent implantation for refractory slow transit constipation.

Proceeding to permanent implantation after an insufficient therapeutic trial response is contraindicated. The policy lists insufficient clinical response during the test phase as an absolute contraindication and explicitly states that patients who do not demonstrate adequate benefit during testing should not proceed to full implantation.

Within the provided excerpts there are no additional explicit ‘Not Medically Necessary’ conditions beyond those already described for constipation, chronic pelvic pain, and proceeding after an insufficient trial response. Policy history entries document terminology and documentation updates but do not add other exclusion conditions in these excerpts.

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.

Device HCPCS 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

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Postvoid residual (PVR) threshold for chronic urinary retention

PVR thresholdPostvoid residual (PVR) ≥ 300 mL documented on ≥ 2 separate occasions

Duration requirementPVR criteria must persist for ≥ 6 months

DocumentationPVR measurements must be recorded on at least 2 occasions in the medical record

Bladder capacity threshold for urinary indications

Bladder capacity thresholdBladder capacity of 100 mL or greater

ApplicabilityRequired for urinary voiding dysfunction indications (e.g., OAB, UUI, NOUR)

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for the procedures and implantable device codes listed in the Applicable Codes section. Providers should obtain prior authorization before scheduling sacral nerve stimulation (SNS/SNM) test trials or permanent implantation to confirm benefit coverage and streamline claims processing.

Verify prior authorization for both percutaneous testing (PNE) and permanent implantation codes
Include device HCPCS (L86xx) codes when applicable

Prior Authorization

Prior Authorization: Documented Test Response Required

Prior authorization approvals for permanent SNS implantation require documentation of a successful documented test-phase response. A successful screening trial is generally defined as ≥ 50% improvement in symptoms (or return to < 8 voids/day for frequency) compared to baseline. Upload objective and subjective measures (voiding diaries, incontinence episode counts, patient-reported improvement) with the authorization request.

Documented ≥50% symptom improvement (or return to <8 voids/day) required prior to permanent implant authorization

Background and Clinical Context

Sacral nerve stimulation (SNS/SNM) is an implanted neurostimulation therapy that uses an electrode placed near a sacral nerve (commonly S3) connected to a pulse generator to modulate pelvic floor and voiding function. It is used clinically for overactive bladder, urge urinary incontinence, nonobstructive urinary retention, and fecal incontinence; a screening trial (commonly percutaneous nerve evaluation or Stage 1 testing) is performed and permanent implantation is considered when the trial demonstrates a meaningful clinical response.

Definitions and Key Terms

Chronic Urinary Retention

DefinitionPostvoid residual (PVR) ≥ 300 mL that persists for ≥ 6 months and is documented on ≥ 2 separate occasions

Clinical contextUsed to define chronic urinary retention as a criterion for evaluation and consideration of therapies

Source guidanceDefinition cited from Stoffel et al., 2016 as included in policy definitions

Fecal Incontinence

DefinitionInvoluntary passage of fecal matter or inability to control the discharge of bowel contents

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

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS358TN.E

Change TypeModified — documentation and references updated

Effective DateDec 1, 2025

Next Review Date

Key ActionObtain and retain legible medical records documenting test-phase success (≥50% improvement) and prior conservative therapy to support prior authorization and coverage.

SourceLink

On This Page

Neurogenic lower urinary tract dysfunction (nLUTD) and urinary retention secondary to neurologic disease: Evidence is limited but emerging; SNM may be considered in carefully selected individuals with neurogenic bladder or bowel dysfunction refractory to conservative treatments and at low risk of upper tract deterioration, with trial phase success predicting outcomes.trial phase success and careful selection

Systematic reviews report improvements in several urodynamic and diary measures, but overall evidence quality varies.

Prior Authorization

Test Phase (PNE) Required Prior to Permanent Implant

A trial stimulation phase (e.g., percutaneous nerve evaluation, PNE) is expected and must precede permanent implant in most covered indications. The trial phase is the most valued predictor of long‑term therapeutic success; insufficient response during trial is an absolute contraindication to permanent implantation.

Perform and document PNE or equivalent test trial prior to permanent SNM implantation
Record objective outcomes from the trial (percent improvement, voiding diary, frequency/UI episode counts)

Denial Risk

Triggers for Potential Denial

Coverage may be denied in specific situations. Individuals under 18 years of age, those with urinary or fecal symptoms secondary to neurologic disease listed in exclusions, or those with contraindications (insufficient trial response, inability to operate device, pregnancy) are at higher risk for denial.

Age < 18 — not covered by this policy
Symptoms secondary to neurologic disease (e.g., Parkinson's, stroke, SCI, MS) — may be excluded
Insufficient clinical response to trial phase — absolute contraindication to permanent implant

Prior Authorization

Test Phase Response Requirement

Successful response during the test phase is required to proceed to permanent implantation. Lack of an adequate response (commonly defined as <50% improvement) should preclude permanent device implantation and may result in denial of services.

Document trial-phase outcomes showing ≥50% improvement for authorization and medical necessity
If trial-phase improvement is <50%, do not proceed to permanent implant

Documentation Required

Documentation‑Dependent Coverage / Denial Risk

Coverage determination is documentation‑dependent. Medical records must fully support medical necessity; incomplete or missing documentation may result in denial or noncoverage. Maintain legible records and make them available upon request.

Include relevant medical history, physical exam, diagnostic test results, and prior therapies tried
Provide records upon request to support medical necessity

Documentation Required

Medical Records Required

The patient's medical record must contain documentation that fully supports the medical necessity for the requested services. Required documentation includes relevant medical history, physical examination findings, and results of diagnostic tests or procedures used to establish eligibility for SNS/SNM.

Include voiding diaries, prior treatment history, urodynamic testing if performed, and documentation of conservative therapy trials
Ensure documentation is legible and retrievable upon request

Documentation Required

Trial Phase Importance

The trial (screening) phase is emphasized across guidelines and literature as the most predictive step for long‑term success with SNS/SNM. Authorization and coverage expectations reflect the importance of a documented, objective trial phase.

Use trial-phase results to support medical necessity for permanent implant
Report trial duration, response metrics, and complications in the record

Documentation Required

Consent and Counseling Documentation

Obtain and document informed consent and counseling that covers risks, potential need for additional surgeries or device removal, the probability of trial success, long‑term commitment to therapy, and device operation requirements.

Document discussion of risks (infection, lead migration, pain, revision rates), potential need for further surgery, and device removal possibility
Document that patient/caregiver capacity to operate device was assessed and discussed

Step Therapy

Conservative Therapy Prerequisite

Conservative therapy failure is a prerequisite for trial and permanent implantation in most indications. Document prior conservative measures (bladder/bowel training, pelvic floor rehabilitation, pharmacologic therapy) and their outcomes before requesting authorization for a trial or implant.

List prior behavioral, physical therapy, and medication trials and durations
Document intolerance or contraindications to alternatives when applicable (e.g., BTX)

Note

Placement in Therapeutic Sequence

Sacral neuromodulation is generally positioned as a third‑line therapy after behavioral and pharmacologic therapies, and as an alternative to or following botulinum toxin in some cases. Consider SNM relative to PTNS and BTX in the treatment sequence and document why SNM is the appropriate next option.

Document prior failure or intolerance of behavioral and pharmacologic therapies
If BTX or PTNS were considered or tried, document response or reasons for choosing SNM

Note

Placement in Treatment Sequence

Guidelines variably position SNS as second‑ or third‑line depending on the indication and prior therapies. For OAB/UUI, many guidelines recommend offering SNS for individuals refractory to anticholinergic therapy and/or after consideration of BTX or PTNS; align the care plan and documentation with guideline‑based sequencing.

For OAB/UUI: document prior anticholinergic/beta‑3 agonist trials and reasons for escalation
For NOUR/FI: document conservative care attempts and specialist team evaluation

Step Therapy

Prior Conservative Therapy

Prior conservative therapy must be documented before trial or permanent SNS implantation. For urinary indications, document bladder training, pelvic floor therapy, and pharmacologic therapy trials; for fecal incontinence, document bowel training, bulking agents, and pelvic rehabilitation.

Include durations and outcomes of each conservative therapy tried
If conservative therapy was contraindicated or not tolerated, document rationale

Note

Use of Third‑Party Criteria

UnitedHealthcare may use third‑party clinical criteria tools (for example, InterQual®) to assist in benefit administration. These tools are supplemental to this policy and to federal/state/contractual coverage requirements.

Third‑party criteria may be used to adjudicate individual benefit requests
Submit complete clinical documentation to support decisions even if third‑party tools are applied