Billing and Coding: Sacral Nerve Stimulation for Urinary and Fecal
Incontinence

**Background**  
Sacral Nerve Stimulation for urinary incontinence is covered for the treatment
of urinary urge incontinence, urge-frequency syndrome, and urinary retention
by the CMS National Coverage Determination (NCD) 230.18,
http://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Downloads/ncd103c1_Part4.pdf. Direct stimulation of
the sacral nerve(s) via an electrode array implanted at the level of the
sacrum is the only treatment modality covered by the NCD. In addition,
Noridian will cover sacral nerve stimulation by the same modality for the
treatment of fecal incontinence, effective March 1, 2012.  
  
 **Indications and Limitations**  
  
 **Urinary Incontinence**  
Sacral nerve stimulation is covered for the treatment of urinary urge
incontinence, urgency-frequency syndrome, and urinary retention. Sacral nerve
stimulation involves both a temporary test stimulation to determine if an
implantable stimulator would be effective and a permanent implantation in
appropriate candidates. Both the test and the permanent implantation are
covered.  
  
The NCD describes the following limitations for coverage to all three
conditions:  
 Patient must be refractory to conventional therapy (documented behavioral,
pharmacologic and/or surgical corrective therapy) and be an appropriate
surgical candidate such that implantation with anesthesia can occur.  
 Patients with stress incontinence, urinary obstruction, and specific
neurologic diseases (e.g., diabetes with peripheral nerve involvement) which
are associated with secondary manifestations of the above three indications
are excluded.  
 Patient must have had a successful test stimulation in order to support
subsequent implantation. Before a patient is eligible for permanent
implantation, he/she must demonstrate a 50% or greater improvement through
test stimulation. Improvement is measured through voiding diaries.  
  
Patient must be able to demonstrate adequate ability to record voiding diary
data such that clinical results of the implant procedure can be properly
evaluated.  
  
 **Fecal Incontinence**  
Noridian will cover sacral nerve modulation/stimulation for fecal incontinence
effective March 1, 2012, when all of the following criteria are met:  
  
 Chronic fecal incontinence with greater than two incontinent episodes on
average per week and duration of incontinence greater than six months or for
more than twelve months after vaginal childbirth; AND  
 Documented failure or intolerance to conventional therapy (e.g., dietary
modification, the addition of bulking and pharmacologic treatment); AND  
 A successful percutaneous test stimulation, defined as at least 50%
sustained (more than one week) improvement in symptoms; AND  
 Condition is not related to 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) and/or chronic inflammatory bowel disease; AND  
 Incontinence is not related to another neurologic condition such as
peripheral neuropathy or complete spinal cord injury.  
  
Sacral nerve modulation/stimulation is considered **experimental,
investigational and unproven for the treatment of chronic constipation or
chronic pelvic pain.**  
  
**Sources:**  
Internet Only Manual (IOM) _Medicare National Coverage Determination Manual_
, Publication 100-03, Section 230.18 _Sacral Nerve Stimulation for Urinary
Incontinence_ ;  
Abrams P et al. Fourth International Consultation on Incontinence
recommendations of the International Scientific Committee: evaluation and
treatment of urinary incontinence, pelvic organ prolapse, and fecal
incontinence;  
 _Neurourol Urodyn_. 2010; 29(1):213-40;  
 _Annals of Surgery_ , March 2010, Vol 251, Number 3. _Sacral Nerve
Stimulation for Fecal Incontinence, Results of a 120-Patient Prospective
Multicenter Study_ ;  
Michelsen H, Thompson-Fawcett M, Lundy L, Krogh K, Laurberg S, Buntzen S;  
Six Year Experience with Sacral Nerve Stimulation for Fecal Incontinence;  
 _Dis Colon Rectum_. 2010; 53(4)414-421; Mowatt G, Glazener CMA, Jarrett M.
Sacral nerve stimulation for fecal incontinence and constipation in adults
(Review);  
 _The Cochrane Library_. 2009, Issue 1; National Institute for Health and
Clinical Excellence. Fecal incontinence: the management of fecal incontinence
in adults. NICE Clinical Guideline 49, June 2007;  
Trailblazer Health Enterprises, Local Coverage Determination for _Sacral
Nerve Stimulation_ - 4S-154AB-R9, Effective March 01, 2008