Providers

Medical Policy Upcoming Updates

Notification Date: December 15, 2021

Below are the policies that are new or have been reviewed, along with the determination and summary of any changes.

Coverage Policies

Policy Title	Status	Effective Date	Determination	Summary of Change
Sacral Nerve Stimulation	Re-Reviewed	12/16/2021	Covered for some indications; investigative and therefore not covered for all other indications	Any FDA approved sacral nerve stimulation/ neuromodulation device used for FDA approved indications is covered (e.g., Interstim devices, Axonics devices) for patients who have had a thorough diagnostic work-up and all of the following: Failed conservative treatments (e.g. pelvic floor exercises, pharmacotherapies) Failed surgical treatment or not appropriate candidates for surgical treatment Symptoms result in a significant functional disability A positive response (50 percent or greater improvement in function) to a trial of temporary percutaneous SNS.

Policy Title

Status

Effective Date

Determination

Summary of Change

Sacral Nerve Stimulation

Re-Reviewed

12/16/2021

Covered for some indications; investigative and therefore not covered for all other indications

Any FDA approved sacral nerve stimulation/ neuromodulation device used for FDA approved indications is covered (e.g., Interstim devices, Axonics devices) for patients who have had a thorough diagnostic work-up and all of the following:

Failed conservative treatments (e.g. pelvic floor exercises, pharmacotherapies)
Failed surgical treatment or not appropriate candidates for surgical treatment
Symptoms result in a significant functional disability
A positive response (50 percent or greater improvement in function) to a trial of temporary percutaneous SNS.

The updated clinical policies and guidelines above will be available as of their effective date, as noted. View policies and guidelines.

To request paper copies of a policy, please leave a message at the Medica Provider Literature Request Line: 1-800-458-5512, option 1, then option 8, then ext. 2-2355.

Where information conflicts with applicable state and/or federal law, Medica follows such applicable federal and/or state law.