Urinary Incontinence and Nonobstructive Retention
Criteria A
A trial period of sacral nerve neuromodulation with either percutaneous nerve stimulation or a temporarily implanted lead may be considered medically necessary in individuals who meet all of the following criteria:
1. There is a diagnosis of at least 1 of the following:
a. Urge incontinence
b. Urgency-frequency syndrome
c. Nonobstructive urinary retention
d. Overactive bladder
2. There is documented failure or intolerance to at least 2 conventional conservative therapies (eg, behavioral training such as bladder training, prompted voiding, or pelvic muscle exercise training, pharmacologic treatment for at least a sufficient duration to fully assess its efficacy, and/or surgical corrective therapy).
a. The individual is an appropriate surgical candidate.
b. Incontinence is not related to a neurologic condition.
Criteria B
Permanent implantation of a sacral nerve neuromodulation device may be considered medically necessary in individuals who meet all of the following criteria:
1. All of criteria A.1 and 2 above are met.
2. A trial stimulation period demonstrates at least 50% improvement in symptoms over a period of at least 48 hours.
Other urinary/voiding applications of sacral nerve neuromodulation are considered investigational, including but not limited to the treatment of stress incontinence or urge incontinence due to a neurologic condition (eg, detrusor hyperreflexia, multiple sclerosis, spinal cord injury, other types of chronic voiding dysfunction).
Fecal Incontinence
Criteria A
A trial period of sacral nerve neuromodulation with either percutaneous nerve stimulation or a temporarily implanted lead may be considered medically necessary in individuals who meet all of the following criteria:
1. There is a diagnosis of chronic fecal incontinence of more than 2 incontinent episodes on average per week for more than 6 months or for more than 12 months after vaginal childbirth.
2. There is documented failure or intolerance to conventional conservative therapy (eg, dietary modification, the addition of bulking and pharmacologic treatment) for at least a sufficient duration to fully assess its efficacy.
3. The individual is an appropriate surgical candidate.
4. The condition is not related to an anorectal malformation (eg, congenital anorectal malformation; defects of the external anal sphincter over 60°; visible sequelae of pelvic radiation; active anal abscesses and fistulae) or chronic inflammatory bowel disease.
5. Incontinence is not related to a neurologic condition.
6. 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.
Criteria B
Permanent implantation of a sacral nerve neuromodulation device may be considered medically necessary in individuals who meet all of the following criteria:
1. All of criteria A.1 through 6 above are met.
2. A trial stimulation period demonstrates at least 50% improvement in symptoms over a period of at least 48 hours.
Sacral nerve neuromodulation is investigational in the treatment of chronic constipation or chronic pelvic pain.
