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Point32Commercial Clinical Policy

Point32 Implantable Neurostimulators Form


Sacral Nerve Stimulators for Urinary Incontinence: Temporary Trial

Indications

(245900) Does the patient have a diagnosis of urinary urgency with or without incontinence, urinary urgency associated with frequency and/or nocturia in the absence of infection or other pathology, OR non-obstructive urinary retention unrelated to a neurologic condition? 
(245901) Has the patient experienced urinary incontinence for a minimum of 12 months not related to other neurologic conditions that cause secondary manifestations? 
(245902) Has there been documented failure of, or are symptoms refractory to, at least two types of conservative therapies (e.g., behavioral interventions, dietary modifications, bladder training, trial of anticholinergic or beta-agonist medications)? 

Sacral Nerve Stimulators for Urinary Incontinence: Permanent

Indications

(245903) Has the patient met the criteria for a temporary trial of Sacral Nerve Stimulators for urinary incontinence? 
(245904) Has the patient undergone a successful trial with at least a 50% reduction in catheter volume/catheterization? 

YesNoN/A
YesNoN/A
YesNoN/A

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Effective Date

08/01/2023

Last Reviewed

NA

Original Document

  Reference



Epilepsy Bibliography

  • Medtronic Inc.; 2018. Accessed April 19, 2021.

Evaluation and Management of Drug-Resistant Epilepsy

UpToDate.com/login [via subscription only]. Accessed April 19, 2021.

Fecal Incontinence in Adults: Management

UpToDate.com/login [via subscription only]. Accessed April 19, 2021.

  1. Gormley, EA., Lightner, DJ., Faraday, M., et al. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline amendment. J Urol. 2015; 193(5): 1572.
  2. Implantable Sacral Nerve Stimulation for Urinary Voiding Dysfunction. Hayesinc.com/subscribers [via subscription only]. Accessed April 19, 2021.
  3. Management of Gastroparesis. Giorg. 2013. Available at: https://gi.org/guideline/management-of-gastroparesis/. Accessed April 19, 2021.
  4. Medical Technology Directory. Gastric electrical stimulation for gastroparesis. Hayesinc.com/subscribers [via subscription only]. Accessed April 19, 2021.
  5. Medtronic DBS Therapy for Epilepsy. U.S. Food and Drug Administration; 2018. Accessed April 19, 2021.

National Coverage Determination (NCD) for Deep Brain Stimulation for Essential Tremor and Parkinson's Disease (160.24). https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=279&ncdver=1&bc=AAAAgAAAAAAAAA%3d%3d&

HPHC Medical Policy Page 7 of 8 Implantable Neurostimulators 6741294 VBO1 AUG23 PVB01 AUG23 P

HPHC policies are based on medical science, and written to apply to the majority of people with a given condition. Individual members' unique clinical circumstances, and capabilities of the local delivery system are considered when making individual UM determinations. Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group. Please reference appropriate member materials (e.g., Benefit Handbook, Certificate of Coverage) for member-specific benefit information.

National Coverage Determinations (NCD)

Other Significant Topics
  • Occipital Nerve Stimulation for Chronic Cluster Headache and Chronic Migraine. Hayesinc.com/subscribers [via subscription only]. Accessed May 4, 2020.
  • Treatment of chronic pain. UpToDate.com/login [via subscription only]. Accessed April 19, 2021.
  • Panebianco M, Zavanone C, Dupont S, Restivo D, Pavone A. Vagus nerve stimulation therapy in partial epilepsy: a review. Acta Neurologica Belgica. 2016;116(3):241-248. doi:10.1007/s13760-016-0616-3.
  • Spinal Cord Stimulation for Relief of Neuropathic Pain. Hayesinc.com/subscribers [via subscription only]. Accessed April 19, 2021.

Stewart, F., Gameiro, OL., El Dib, R., et al. Electrical stimulation with non-implanted electrodes for overactive bladder in adults. Cochrane Database Syst Rev. 2016; 4: CD010098.

Summary of Safety and Effectiveness Data (SSED). U.S. Food and Drug Administration; 2018. Accessed April 19, 2021.

Surgical Treatment
  • Of essential tremor. UpToDate.com/login [via subscription only]. April 19, 2021.
  • Of Parkinson disease. UpToDate.com/login [via subscription only]. Accessed April 19, 2021.

UpToDate.com/login [via subscription only]. Accessed April 19, 2021.

  1. Treatment of dystonia. UpToDate.com/login [via subscription only]. Accessed April 19, 2021.
  2. Treatment of urinary incontinence in women. UpToDate.com/login [via subscription only]. Accessed April 19, 2021.
  3. Vagus Nerve Stimulation for Depression. Hayesinc.com/subscribers [via subscription only]. Accessed April 19, 2021.
  4. Vagus Nerve Stimulation for Epilepsy. Hayesinc.com/subscribers [via subscription only]. Accessed April 19, 2021.
  5. Vagus nerve stimulation therapy for the treatment of epilepsy. UpToDate.com/login [via subscription only]. Accessed April 19, 2021.

Zesiewicz T, Elble R, Louis E et al. Evidence-based guideline update: Treatment of essential tremor: Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2011;77(19):1752-1755. doi:10.1212/wnl.0b013e318236f0fd.

Summary of Changes
  • Date: 6/23
    Change: Coding updated
  • Date: 10/22
    Change: Criteria updated for Integration with Tufts Health Plan (THP)
  • Date: 7/22
    Change: Annual review; no changes
  • Date: 5/21
    Change: Annual review; criteria and coding updated
  • Date: 6/20
    Change: Annual review; adoption of IQ criteria, coding updated
  • Date: 6/19
    Change: Annual review; no changes
  • Date: 3/18
    Change: Background and references updated; policy coverage criteria refined
  • Date: 3/17
    Change: Updated coding to reflect deleted code
  • Date: 8/16
    Change: Updated references. Minor formatting changes.

Approved by Medical Policy Committee: 6/21/23
Approved by Clinical Policy Operational Committee: 2/15; 8/16; 3/17; 3/18; 6/19; 8/20; 5/21; 8/22; 11/22; 7/23
Policy Effective Date: 08/01/2023
Initiated: 7/1/15

HPHC Medical Policy
Implantable Neurostimulators 6741294 VBO1 AUG23 PVB01 AUG23 P

HPHC policies are based on medical science, and written to apply to the majority of people with a given condition. Individual members’ unique clinical circumstances, and capabilities of the local delivery system are considered when making individual UM determinations.
Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group. Please reference appropriate member materials (e.g., Benefit Handbook, Certificate of Coverage) for member-specific benefit information.