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