Description
Documentation will be reviewed to determine if sacral nerve stimulation for urinary or fecal incontinence meets Medicare coverage criteria, and/or is medically reasonable and necessary.
Affected Code(s)
64561, 64581, 64585, 64590, 64595, A4290, C1767, C1778, C1820, C1883, C1897, L1879, L8680, L8685, L8686, L8687, L8688, L8689
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 §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 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
6. 42 CFR §405.986- Good Cause for Reopening
7. Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, §230.18- Sacral Nerve Stimulation for Urinary Incontinence
8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
9. Medicare Claims Processing Manual, Chapter 32- Billing Requirements for Special Services, §40- Sacral Nerve Stimulation
10. First Coast Service Options, Inc., LCD L36296- Sacral Neuromodulation, Effective 10/01/2015; Retired 8/13/2020
11. First Coast Service Options, Inc., LCA A56508 - Billing and Coding: Sacral Neuromodulation, Effective 01/08/2019, Retired 08/13/2020
12. Novitas Solutions, Inc., LCD L35449- Sacral Nerve Stimulation, Effective 10/01/2015; Retired 8/13/2020
13. Novitas Solutions, Inc., LCA A57617- Billing and Coding: Sacral Nerve Stimulation, Effective 10/31/2019; Retired 8/13/2020
14. Noridian Healthcare Solutions, LLC, LCA A53017- Billing and Coding: Sacral Nerve Stimulation for Urinary and Fecal Incontinence, Effective 10/01/2015; Revised 01/01/2020
15. Noridian Healthcare Solutions, LLC, LCA A53359- Billing and Coding: Sacral Nerve Stimulation for Urinary and Fecal Incontinence, Effective 10/1/2015; Revised 01/01/2020
16. CGS Administrators, LLC, LCA A55835- Billing and Coding: Sacral Nerve Stimulation for Urinary and Fecal Incontinence, Effective 2/01/2018; Revised 03/02/2023
17. AMA CPT Codebook
18. HCPCS Level II Codebook