Anthem Blue Cross Connecticut CG-SURG-08 Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury Form

This document addresses sacral nerve stimulation as a treatment of neurogenic bladder due to spinal cord injury. The device consists of extradural electrodes that are attached to the sacral anterior nerve roots, a subcutaneously implanted receiver-stimulator, and an external battery-powered controller and transmitter. The system is self-activated and provides low levels of electrical stimulation designed to produce functional contraction of the innervated muscles. Implantation is frequently performed in conjunction with a posterior rhizotomy to eliminate reflex incontinence.

Note: Please see the following related documents for additional information:

• SURG.00010 Treatments for Urinary Incontinence
• CG-SURG-95 Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention

Clinical Indications

Medically Necessary:

Self-activated electrical stimulation of intact anterior sacral nerve roots using an implantable device (for example, Vocare Bladder System/FineTech Brindley Bladder Control System) to provide urination on demand and reduce post-void residual volume is considered medically necessary for individuals who meet all of the following criteria:

• Have a neurogenic bladder due to a clinically complete* suprasacral spinal cord lesion; and
• Have intact parasympathetic innervation of the bladder; and
• Are skeletally mature and neurologically stable; and
• Cannot be adequately managed with intermittent or condom catheterization.

Not Medically Necessary:

Self-activated electrical stimulation of the anterior sacral roots is considered not medically necessary for all other indications.

*As defined by the American Spinal Injury Association (ASIA) Impairment Scale.