0003 - Sacral Neurostimulation: Medical Necessity and Documentation Requirements

Issue Name
0003 - Sacral Neurostimulation: Medical Necessity and Documentation Requirements
Date
Review Type
Complex
Provider Type
Ambulatory Surgical Center (ASC); Inpatient Hospital; Outpatient Hospital; Professional Services
MAC Jurisdiction
Urinary incontinence- All A/B MACs Fecal incontinence- JE, JF, JH, JL, JN, J15

Description

Claims for sacral nerve stimulation for urinary incontinence or fecal incontinence not deemed to be medically necessary will be denied.

Affected Code(s)

64561, 64581, 64590, A4290, C1767, C1778, C1883, C1897  

Applicable Policy References

1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor;  and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
4. 42 CFR §405.986- Good Cause for Reopening  
5. National Coverage Determination 230.18- Sacral Nerve Stimulation for Urinary Incontinence, Effective 1/1/2002
6. Medicare Claims Processing, Chapter 32- Billing Requirements for Special Services, Section 40- Sacral Nerve Stimulation
7. First Coast Service Options, Inc., LCD L36296- Sacral Neuromodulation, Effective 10/1/2015; Revised 08/06/2019 
8. Novitas Solutions, Inc., LCD L34707- Sacral Nerve Stimulation, Effective 07/24/2014; Retired 09/30/2015 
9. Novitas Solutions, Inc., LCD L35449- Sacral Nerve Stimulation, Effective 10/1/2015; Revised 04/18/2019 
10. Noridian Healthcare Solutions, LLC, LCA A51767 Article for Sacral Nerve Stimulation for Urinary and Fecal Incontinence R3, Effective 04/20/2012; Retired 9/30/2015
11. Noridian Healthcare Solutions, LLC, LCA A53017- Sacral Nerve Stimulation for Urinary and Fecal Incontinence, Effective 10/1/2015; Revised  02/28/2019
12. Noridian Healthcare Solutions, LLC, LCA A53359- Sacral Nerve Stimulation for Urinary and Fecal Incontinence, Effective 10/1/2015; Revised  02/28/2019
13. CGS Administrators, LLC, LCA A55835- Sacral Nerve Stimulation for Urinary and Fecal Incontinence, Effective 02/01/2018
14. CPT Assistant, December 2012, Volume 22, Issue 12, page 14- Surgery: Nervous System, Placement Permanent Neurostimulator Electrode Array with Implant of Pulse Generator