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    v1.0.28
    OpenPayerPolicy UpdatesUrologyUtah Health Plans Sacral Nerve Update | OpenPayer
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    ModifiedUniversity of Utah Health PlansPolicy MP-076

    Sacral Nerve Stimulation for Pelvic Floor Dysfunction

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    This policy governs coverage of sacral nerve neuromodulation, including trial stimulation, permanent implantation, and device replacement, revision, or removal for selected urinary and fecal dysfunction indications. It applies to University of Utah Health Plans Commercial, CHIP, Healthy U Medicaid, and Health Choice Utah Medicaid plans, subject to plan benefits, eligibility, and applicable Medicaid coverage rules.

    Policy Summary
    PayerUniversity of Utah Health Plans
    PolicySacral Nerve Stimulation for Pelvic Floor Dysfunction
    Policy CodePolicy MP-076
    Change TypeModified
    Effective DateSep 28, 2026
    Last ReviewAug 28, 2026
    Next Review DateAug 28, 2027
    Key ActionObtain prior authorization whenever the service requires it before performing the service.
    SourceLink
    POLICY UPDATE CHANGES

    Urinary-indication coverage criteria were updated to include overactive bladder, urgency urinary incontinence, and non-obstructive urinary retention.

    A 6-month symptom-duration requirement and an obstruction exclusion were added for urinary indications.

    Fecal incontinence criteria were revised to specify chronic refractory fecal incontinence.

    Member participation requirements for device management were added for urinary and fecal incontinence indications.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    6 monthsMinimum urinary symptom duration for trial coverage
    50%Minimum response required for permanent implantation
    2/weekMinimum fecal incontinence frequency for trial coverage
    6 or 12 monthsRequired fecal symptom duration
    InvestigationalOther urinary, bowel, pelvic floor, or voiding indications
    2 stagesTypical treatment sequence

    Medical Necessity and Coverage Criteria

    Urinary Incontinence — Trial Stimulation

    Covered when ALL of the following criteria are met:

    ALL of the following

    • At least ONE diagnosis

      • Overactive bladder with urinary urgency, frequency, nocturia, and/or urinary incontinence
      • Urgency urinary incontinence
      • Non-obstructive urinary retention
    • Symptoms have been present for at least 6 months and result in clinically significant impairment of daily functioning and/or quality of life

    • Conservative treatment

      • Symptoms are refractory to, the member has a contraindication to, or the member is intolerant of conservative treatment of sufficient duration to fully assess treatment effect
      • Behavioral therapy, such as bladder training, fluid management, pelvic floor muscle training, or pelvic floor physical therapy with or without biofeedback, has been attempted when appropriate
      • Pharmacologic therapy has been attempted when clinically appropriate
    • For non-obstructive urinary retention, urinary retention is not due to a mechanical obstruction, such as urethral stricture, obstructing malignancy, or significant benign prostatic obstruction
    • The member is an appropriate surgical candidate and is capable of participating in device operation, management, and required follow-up
    • Symptoms are not primarily due to a spinal cord injury, neurogenic bladder, or progressive neurologic disease

    Urinary Incontinence — Permanent Implantation

    Covered when ALL of the following criteria are met:

    ALL of the following

    • All criteria for urinary incontinence trial stimulation have been met
    • A successful trial stimulation has been documented, demonstrated by at least a 50% improvement in baseline symptoms≥ 50% improvement

    • At least ONE documented measure of improvement

      • Reduction in urinary incontinence episodes
      • Reduction in pad utilization

    Fecal Incontinence — Trial Stimulation

    Covered when ALL of the following criteria are met:

    ALL of the following

    • Chronic refractory fecal incontinence

      • The member has chronic refractory fecal incontinence with an average of at least 2 incontinent episodes per week≥ 2 episodes per week
      • Symptoms have been present for at least 6 months, or for at least 12 months following vaginal childbirth
    • The member has failed, is intolerant of, or has a contraindication to conservative treatment of sufficient duration to assess treatment effect, including dietary modification, pharmacologic therapy when appropriate, bowel training programs, and/or pelvic floor rehabilitation or biofeedback
    • The member is an appropriate surgical candidate and capable of participating in device management and required follow-up

    Fecal Incontinence — Permanent Implantation

    Covered when BOTH of the following criteria are met:

    BOTH of the following

    • All criteria for fecal incontinence trial stimulation have been met
    • Trial stimulation demonstrates at least a 50% improvement in baseline symptoms≥ 50% improvement

    Replacement, Revision, or Removal

    Covered when ANY of the following criteria are met:

    ANY of the following

    • The device is no longer functioning appropriately
    • Battery depletion has occurred, and the member has previously demonstrated clinical benefit
    • Lead migration or lead malfunction has occurred
    • Infection, erosion, pain, or another device-related complication is present
    • Removal is necessary because the device is no longer effective or no longer tolerated

    For non-obstructive urinary retention, coverage requires that the retention is not due to a mechanical urinary outlet obstruction, such as urethral stricture, obstructing malignancy, or significant benign prostatic obstruction. Mechanical urinary outlet obstruction is not a covered indication.

    Fecal incontinence coverage excludes conditions related to anorectal malformation or other specified anorectal conditions, including congenital anorectal malformation, external anal sphincter defects greater than 60 degrees, visible sequelae of pelvic radiation, active anal abscesses, or fistula. Active inflammatory bowel disease and recent rectal surgery are also exclusionary under the applicable coverage criteria.

    Symptoms or incontinence primarily due to spinal cord injury, neurogenic bladder, or progressive neurologic disease are excluded from the applicable urinary and fecal incontinence coverage criteria. Urinary incontinence due to neurologic conditions, including multiple sclerosis, spinal cord injury, detrusor hyperreflexia, or other neurogenic bladder disorders, is investigational.

    Sacral nerve neuromodulation is investigational for all other urinary, bowel, pelvic floor, or voiding indications, including stress urinary incontinence, urinary incontinence due to neurologic conditions, mechanical urinary outlet obstruction, chronic constipation, and chronic pelvic pain.

    Coding and Coverage Thresholds

    CPT CodesCPT
    0786TInsertion or replacement of percutaneous electrode array, sacral, with integrated neurostimulator.
    0787TRevision or removal of neurostimulator electrode array, sacral, with integrated neurostimulator.
    0788TElectronic analysis with simple programming of implanted integrated neurostimulation system, including contact group(s), amplitude, pulse width, frequency (Hz), on/off cycling, burst, dose lockout, patient-selectable parameters, responsive neurostimulation, detection algorithms, closed-loop parameters, and passive parameters, when performed by physician or other qualified health care professional, spinal cord or sacral nerve, 1-3 parameters.
    0789TElectronic analysis with complex programming of implanted integrated neurostimulation system, including contact group(s), amplitude, pulse width, frequency (Hz), on/off cycling, burst, dose lockout, patient-selectable parameters, responsive neurostimulation, detection algorithms, closed-loop parameters, and passive parameters, when performed by physician or other qualified health care professional, spinal cord or sacral nerve, 4 or more parameters.
    64561Percutaneous implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) including image guidance, if performed.
    64581Open implantation of neurostimulator electrode array; sacral nerve (transforaminal placement).
    64585Revision or removal of peripheral neurostimulator electrode array.
    64590Insertion 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.
    64595Revision or removal of peripheral, sacral or gastric neurostimulator pulse generator or receiver, with detachable connection to electrode array.
    95971Electronic analysis of implanted neurostimulator pulse generator/transmitter by physician or other qualified health care professional; with simple spinal cord or peripheral nerve neurostimulator pulse generator/transmitter programming.
    1–10 of 11
    1/2
    HCPCS CodesHCPCS
    A4290Sacral nerve stimulation test lead, each.
    C1767Generator, neurostimulator (implantable), non-rechargeable.
    C1778Lead, neurostimulator (implantable).
    C1820Generator, neurostimulator (implantable), with rechargeable battery and charging system.
    C1883Adapter/extension, pacing lead or neurostimulator lead (implantable).
    C1897Lead, neurostimulator test kit (implantable).
    L8679Implantable neurostimulator, pulse generator, any type.
    L8680Implantable neurostimulator electrode, each.
    L8684Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and bladder management, replacement.
    L8685Implantable neurostimulator pulse generator, single array, rechargeable, includes extension.
    1–10 of 13
    1/2
    Urinary symptom duration
    Required durationAt least 6 months
    Applies toUrinary indications undergoing trial stimulation
    Additional requirementSymptoms must cause clinically significant impairment of daily functioning and/or quality of life
    Successful trial response
    Required responseAt least 50% improvement in baseline symptoms
    Permanent implantationThe successful response must be documented after trial stimulation

    Authorization, Documentation, and Denial Risks

    Prior Authorization

    Prior Authorization Required

    Obtain required prior authorization before performing services subject to authorization. Services requiring prior authorization may not be covered if authorization is not obtained.

    Step Therapy

    Document Conservative Treatment First

    Assess conservative treatment before proceeding with sacral nerve stimulation and document that symptoms are refractory to treatment, or that treatment was contraindicated or not tolerated, after a sufficient duration to evaluate its effect.

    • Urinary indications: document behavioral therapy, bladder training, fluid management, pelvic floor muscle training or physical therapy, and pharmacologic therapy when clinically appropriate.
    • Fecal indications: document dietary modification, pharmacologic therapy when appropriate, bowel training, pelvic floor rehabilitation, and/or biofeedback.

    Clinical Background

    Sacral nerve neuromodulation, also called sacral nerve stimulation, electrically stimulates the sacral nerve roots—most commonly at the S3 foramen—to modulate bladder, bowel, and pelvic floor function. It is used in selected patients with refractory overactive bladder, urgency urinary incontinence, non-obstructive urinary retention, or chronic fecal incontinence when conservative management has been inadequate. Treatment generally begins with temporary trial stimulation; patients who demonstrate meaningful symptom improvement may proceed to permanent implantation of a lead and neurostimulator.

    Terminology

    Overactive bladder
    Core symptomUrinary urgency
    Common accompanying symptomsUsually urinary frequency and nocturia
    IncontinenceMay occur with or without urgency urinary incontinence
    Urgency urinary incontinence
    DefinitionInvoluntary leakage of urine associated with urinary urgency
    Symptom typeUrinary incontinence associated with urgency
    Policy contextA qualifying urinary indication for sacral nerve neuromodulation
    Policy Summary
    PayerUniversity of Utah Health Plans
    PolicySacral Nerve Stimulation for Pelvic Floor Dysfunction
    Policy CodePolicy MP-076
    Change TypeModified
    Effective DateSep 28, 2026
    Last ReviewAug 28, 2026
    Next Review DateAug 28, 2027
    Key ActionObtain prior authorization whenever the service requires it before performing the service.
    SourceLink
    On This Page
    Medical Necessity and Coverage CriteriaCoding and Coverage ThresholdsAuthorization, Documentation, and Denial RisksClinical BackgroundTerminology
    Reduction in urinary frequency
  1. Increase in voided volume
  2. Reduction in catheterization frequency or catheterized volume
  3. The condition is not related to anorectal malformation, including congenital anorectal malformation, external anal sphincter defects greater than 60 degrees, visible sequelae of pelvic radiation, active anal abscesses, or fistula, and is not related to active inflammatory bowel disease
  4. Incontinence is not primarily due to spinal cord or progressive neurologic disease
  5. The member has not undergone rectal surgery within the previous 12 months, or within the previous 24 months when surgery was performed for rectal cancer
    6. Examples of supporting measures
    Reduced incontinence episodes, pad use, urinary frequency, catheterization, or catheterized volume; or increased voided volume
    Fecal incontinence frequency
    Required frequencyAverage of at least 2 incontinent episodes per week
    ConditionChronic refractory fecal incontinence
    Treatment stageRequired for fecal incontinence trial stimulation
    Fecal symptom duration
    Standard durationAt least 6 months
    After vaginal childbirthAt least 12 months
    ConditionSymptoms must represent chronic refractory fecal incontinence
    Prior rectal surgery interval
    Standard intervalNo rectal surgery within the previous 12 months
    After rectal cancer surgeryNo rectal surgery within the previous 24 months
    Applies toFecal incontinence trial stimulation eligibility
    Successful SNM trial
    Successful trial thresholdAt least 50% improvement in bothersome urinary or bowel symptoms
    PurposeThe trial phase is the most reliable predictor of long-term treatment success
    Treatment sequenceA successful trial may be followed by permanent implantation
    Documentation Required

    Document Baseline Eligibility

    Document baseline eligibility and the clinical factors supporting medical necessity for the trial procedure.

    • Qualifying diagnosis: urinary urgency/frequency/nocturia or urinary incontinence, urgency urinary incontinence, non-obstructive urinary retention, or chronic refractory fecal incontinence.
    • Document symptom duration: at least 6 months for urinary symptoms; fecal incontinence for at least 6 months, or at least 12 months following vaginal childbirth.
    • Document clinically significant impairment of daily functioning and/or quality of life for urinary indications and the required fecal episode frequency of at least 2 incontinent episodes per week.
    • Document relevant exclusions, including mechanical obstruction, anorectal conditions, active inflammatory bowel disease, recent rectal surgery, spinal cord or progressive neurologic disease, and surgical candidacy.
    Documentation Required

    Document Trial Response Before Implantation

    Before permanent implantation, document that all trial criteria were met and record the trial response. A successful trial requires at least 50% improvement from baseline.

    • Urinary response may be shown by reduced incontinence episodes, reduced pad use, reduced urinary frequency, increased voided volume, or reduced catheterization frequency or catheterized volume.
    • For fecal incontinence, document trial stimulation improvement of at least 50% from baseline.
    Documentation Required

    Document Device-Related Indication

    For replacement, revision, or removal, document the specific device-related indication and the clinical rationale for the requested service.

    • Examples include device malfunction, battery depletion with prior clinical benefit, lead migration or malfunction, infection, erosion, pain, another device-related complication, or loss of effectiveness or tolerance.

    Unsupported block type: billing_rule

    Unsupported block type: denial_risk

    Denial Risk

    Investigational Indications May Be Denied

    Do not submit sacral nerve neuromodulation as medically necessary for investigational indications. Such indications include stress urinary incontinence, neurologic or neurogenic bladder conditions, mechanical urinary outlet obstruction, chronic constipation, and chronic pelvic pain.

    • Examples of neurologic conditions include multiple sclerosis, spinal cord injury, detrusor hyperreflexia, and other neurogenic bladder disorders.
    Denial Risk

    Incomplete Criteria Create Denial Risk

    Trial or permanent implantation may be denied when the complete medical-necessity criteria are not documented or are not met. Permanent implantation requires all applicable trial criteria plus the required documented trial response.

    • Urinary trial criteria include a qualifying diagnosis, symptoms for at least 6 months with significant functional or quality-of-life impact, appropriate conservative-treatment history, no mechanical obstruction for retention, surgical candidacy, ability to manage the device and follow-up, and no primary spinal cord, neurogenic, or progressive neurologic cause.
    • Fecal trial criteria include chronic refractory incontinence, the required episode frequency and duration, appropriate conservative-treatment history, surgical candidacy, ability to manage the device and follow-up, and absence of specified anorectal, inflammatory, neurologic, or recent-surgery exclusions.
    Step Therapy

    Meet Step-Therapy and Suitability Requirements

    Ensure conservative treatment and patient-suitability requirements are satisfied and documented before requesting authorization. Failure to establish adequate treatment failure, intolerance, contraindication, surgical candidacy, device-management ability, or required follow-up may result in denial.

    • Document that conservative treatment was assessed first and was refractory, contraindicated, or not tolerated.
    • Document the patient’s ability to participate in device operation, management, and required follow-up.
    Non-obstructive urinary retention
    DefinitionImpaired bladder emptying in the absence of a mechanical outlet obstruction
    Examples excluded as causesUrethral stricture, obstructing malignancy, or significant benign prostatic obstruction
    Policy contextRetention must not be due to mechanical obstruction
    Fecal incontinence
    DefinitionInvoluntary loss of solid or liquid stool
    Affected functionBowel continence
    Policy contextA qualifying indication when chronic and refractory and other criteria are met
    Sacral nerve neuromodulation
    Alternative nameSacral nerve stimulation (SNS)
    MechanismElectrical stimulation of the sacral nerve roots, most commonly at the S3 foramen
    Function influencedBladder, bowel, and pelvic floor function
    Evidence-context definition of overactive bladder
    Evidence definitionUrinary frequency and urgency symptoms, with or without urgency urinary incontinence
    Evidence populationAdults with overactive bladder evaluated in systematic reviews and randomized trials
    Common outcome measureChanges in micturition frequency, urgency episodes, and urgency urinary incontinence episodes
    Evidence-context definition of urgency urinary incontinence and response measurement
    Evidence definitionUrinary incontinence associated with urinary urgency
    Common response thresholdAt least a 50% reduction in urgency urinary incontinence episodes
    Assessment methodsBladder diaries and changes in urgency, frequency, urinary incontinence episodes, and quality of life
    Evidence-context definition of fecal incontinence and assessment measures
    Evidence definitionLoss of bowel control or involuntary stool leakage
    Diary measureBowel diaries documenting incontinent episodes
    Validated assessmentIncontinence severity scores and changes in quality of life may be used
    Evidence-context definition of sacral neuromodulation or sacral nerve stimulation
    Alternative nameSacral nerve stimulation (SNS)
    Device componentsAn implanted lead and neurostimulator
    Clinical useTreatment of selected urinary or fecal incontinence conditions