HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 
Medical Policy:
S-131-030
Topic:
Sacral Nerve Neuromodulation
Section:
Surgery
Effective Date:
September 2, 2024
Issued Date:
September 2, 2024
Last Revision Date:
July 2024
Annual Review:
July 2024
 
 

Sacral nerve neuromodulation (SNM) is defined as the implantation of a permanent device that modulates the neural pathways controlling bladder or rectal function.

Policy Position

Urinary Incontinence and Non-obstructive Retention

A trial period of SNM (e.g., InterStim Continence Control Therapy System), with either percutaneous nerve stimulation or a temporarily implanted lead may be considered medically necessary when ALL of the following criteria are met

  • The individual has a diagnosis of ONE or more of the following
    • Urinary urge incontinence
    • Urgency-frequency syndrome
    • Non-obstructive urinary retention
    • Overactive bladder
  • The individual has failed or has an intolerance to TWO or more of the following conventional conservative techniques (this list in not all inclusive)
    • Behavioral training including ONE or more of the following
      • Bladder training
      • Prompted voiding
      • Pelvic muscle training
    • Pharmacological treatment for at least a sufficient duration to fully assess its efficacy
    • Surgical corrective therapy
  • The individual is an appropriate surgical candidate
  • Incontinence is not related to a neurologic condition

Permanent implantation of a sacral nerve neuromodulation device may be considered medically necessary when ALL of the following criteria are met:

  • Criteria for a trial period of SNM was met
  • A trial stimulation period demonstrates at least 50% improvement in symptoms over a period of at least 48 hours.

Sacral nerve neuromodulation is not covered for ANY of the following

  • Treatment of stress or urge incontinence due to a neurologic condition including but not limited to ALL of the following
    • Detrusor hyperreflexia
    • Multiple sclerosis
    • Spinal cord injury
    • Other types of chronic voiding dysfunction

SNM for urinary/voiding applications not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore, non-covered, because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

0786T

0787T

0788T

0789T

64561

64581

64585

64590

64595

95970

95971

95972

A4290

E0745

E1399

L8678

L8679

L8680

L8681

L8685

L8686

L8687

L8688

 

 

 

 

 


Fecal Incontinence

A trial period of SNM with either percutaneous nerve stimulation or a temporarily implanted lead may be considered medically necessary when ALL of the following are met

  • The individual has a diagnosis of chronic fecal incontinence with greater than 2 incontinent episodes on average per week with duration greater than 6 months or for more than 12 months after vaginal childbirth
  • The individual has failed or has an intolerance to conventional therapy including ONE or more of the following for at least a sufficient duration to fully assess efficacy
    • Dietary modification
    • Bulking and pharmacologic treatment
    • Pelvic floor rehabilitation
    • Bowel training
  • The individual has not had rectal surgery in the previous 12 months, or, in the case of cancer, the individual has not had rectal surgery in the past 24 months
  • The individual is an appropriate surgical candidate
  • The condition is not related to an anorectal malformation (e.g., congenital anorectal malformation; defects of the external anal sphincter over 60 degrees; visible sequelae of pelvic radiation; active anal abscesses and fistulae) or chronic inflammatory bowel disease
  • Incontinence is not related to another neurologic condition

Permanent implantation of a sacral nerve neuromodulation device may be considered medically necessary when ALL of the following criteria are met:

  • Criteria for a trial period of SNM was met
  • A trial stimulation period demonstrates at least 50% improvement in symptoms over a period of at least 48 hours.

SNM for treatment of fecal incontinence not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore, non-covered, because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

0786T

0787T

0788T

0789T

64561

64581

64585

64590

64595

95970

95971

95972

A4290

E0745

E1399

L8678

L8679

L8680

L8681

L8685

L8686

L8687

L8688

 

 

 

 

 


C1767

C1778

C1816

C1820

C1822

C1823

C1826

C1827

C1883

C1897

 

 

 

 


Related Policies

Refer to Medical Policy Z-7, Electrical Nerve Stimulation, for additional information.


Professional Statements and Societal Positions Guidelines

Urinary Disorders American Urological Association - 2014

The American Urological Association (2014) updated its guidelines on the diagnosis and treatment of overactive bladder. The guidelines stated that sacral neuromodulation may be offered as a third-line treatment in carefully selected patients with severe refractory symptoms or into those who are not candidates for second-line therapy (e.g., oral antimuscarinics, oral β3-adrenoceptor agonists, transdermal oxybutynin) and are willing to undergo surgery.

American Urological Association – 2018

The American Urological Association Guidelines for the Management of Urinary Incontinence in Women includes recommendations for SNS for stress urinary incontinence in women, particularly those who have not achieved satisfactory results with other treatments. 

Fecal Disorders National Institute for Health and Care Excellence - 2007

The National Institute for Health and Care Excellence (2007) issued guidance on the management of fecal incontinence. The guidance was reviewed in 2014, and no changes were made. The guidance has recommended:

  • “A trial of temporary sacral nerve stimulation should be considered for people with fecal incontinence in whom sphincter surgery is deemed inappropriate 
  • All individuals should be informed of the potential benefits and limitations of this procedure and should undergo a trial stimulation period of at least 2 weeks to determine if they are likely to benefit.
  • People with fecal incontinence should be offered sacral nerve stimulation on the basis of their response to percutaneous nerve evaluation during specialist assessment, which is predictive of therapy success.” 

American College of Gastroenterology - 2014

In its clinical guideline on the management of benign anorectal disorders, including fecal incontinence, the American College of Gastroenterology (2014) found that "sacral nerve stimulation should be considered in [fecal incontinence] who do not respond to conservative therapy."


Covered Diagnosis Codes for Procedure Codes: A4290, 64561, 64581

N32.81

N39.41

R15.0

R15.1

R15.2

R15.9

R33.0

R33.8

R33.9

R35.0

 

 

 

 


Place of Service: Inpatient/Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

The insertion of a sacral nerve stimulator is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business



Links





This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract, and subject to the applicable laws of your state.


Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as: 
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as: 
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact the Civil Rights Coordinator. 

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. 

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: 

U.S. Department of Health and Human Services 
200 Independence Avenue, SW 
Room 509F, HHH Building 
Washington, D.C. 20201 
1-800-368-1019, 800-537-7697 (TDD) 

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. 

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. 




Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.