0003 - Sacral Neurostimulation: Medical Necessity and Documentation Requirements

Dynamic List Information
Dynamic List Data
Issue Name
0003 - Sacral Neurostimulation: Medical Necessity and Documentation Requirements
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, J15
Date
2017-02-01
RAC Type
Approved

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, 64590

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 Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
8.    Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, §230.18- Sacral Nerve Stimulation for Urinary Incontinence
9.    Medicare Claims Processing Manual, Chapter 32- Billing Requirements for Special Services, §40- Sacral Nerve Stimulation
10.    Noridian Healthcare Solutions, LLC, LCA A53017- Billing and Coding: Sacral Nerve Stimulation for Urinary and Fecal Incontinence, Effective 10/01/2015; Revised 01/01/2024
11.    Noridian Healthcare Solutions, LLC, LCA A53359- Billing and Coding: Sacral Nerve Stimulation for Urinary and Fecal Incontinence, Effective 10/01/2015; Revised 01/01/2024
12.    CGS Administrators, LLC, LCA A55835- Billing and Coding: Sacral Nerve Stimulation for Urinary and Fecal Incontinence, Effective 2/01/2018; Revised 03/7/2024
13.    AMA CPT Codebook
14.    HCPCS Level II Codebook