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Issue Number - Name
0003 - Sacral Neurostimulation- Reasonable and Necessary Requirements and Coding Requirements
Review Type
Complex
Claim Type
Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center, Physician /Professional Services
Region and State
RAC 1-4
All States
Date Approved
2017-02-01

Description

Documentation will be reviewed to determine if Sacral Neurostimulation meets Medicare coverage criteria.

Affected Codes

  • HCPCS: 64561, 64581, 64585, 64590, 64595 A4290, C1767, C1778, C1883, C1897, L8680
  • ICD-9: 595.1, 896.52, 596.55, 787.60, 788.20, 788.21, 788.29, 788.30-788.33, 788.34, 788.38, 788.39, 788.41, 788.63, 788.64, 788.91, 788.99
  • ICD-10: N31.10, N30.11, N31.8, N36.44, N39.3, N39.41, N39.42, N39.46, R15.9, R30.1, R32, R33.0-R33.9, R35.0, R39.11, R39.14, R39.15, R39.16, R39.2, R39.81, R39.89, R39.9

Applicable Policy References

  • Title XVIII of the Social Security Act, Section 1862 (a)(1)(A)
  • 42 Code of Federal Regulations, Section 405.980(b) and (c)
  • 42 Code of Federal Regulations, Section 405.986
  • CMS Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 230.18 
  • CMS Pub. 100-04, Medicare Claims Processing Manual, Chapter 32, Section 40 
  • First Coast LCD, L36296, Effective 10/1/2015
  • Novitas LCD, L35449, Effective 10/1/2015
  • Novitas LCD, L34707, Effective 7/24/14 – 9/30/2015
  • Noridian LCA, A53016, Effective 10/1/2015
  • Noridian LCA, A51767, Effective 4/20/2012-9/30/2015