Effective Date:

a)    This policy will apply to all services performed on or after the above Revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Gastric Pacemakers and Sacral nerve neuromodulation for fecal incontinence require pre-authorization.

2)    Gastric pacemakers are used to treat gastroparesis that has not responded to medical treatment.

3)    Sacral nerve neuromodulation for fecal incontinence

Gastric Pacemakers:

1) “Gastric Pacemaker” means a medical device that:

a)    Uses an external programmer and implanted electrical leads to the stomach; and

b)    Transmits low-frequency, high energy electrical stimulation to the stomach to entrain and pace the gastric slow waves to treat gastroparesis.

1)    Gastric Pacemakers will only be used in medical centers in which an institutional review board has approved use of the device.

2)    If a battery of the neurostimulator runs down, the physician will obtain prior written authorization and approval for a replacement surgery.

3)    Gastric pacing is covered for gastroparesis (K31.84) when:

a)    The nausea and vomiting is debilitating and interfering with activities of daily living and;

b)    An adequate trial (at least 3 months) of medication has failed to control the nausea and vomiting.

Sacral nerve neuromodulation for fecal incontinence:

Sacral nerve neuromodulation requires prior authorization criteria that there be scientific evidence of effectiveness for the treatment of fecal incontinence when all of the following criteria are met:

1)    Chronic fecal incontinence of greater than 2 incontinent episodes on average per week with duration greater than 6 months or for more than 12 months after vaginal childbirth; AND

2)    Documented failure or intolerance to conventional conservative therapy (e.g., dietary modification, the addition of bulking and pharmacologic treatment for at least 6 months and/or surgical corrective therapy performed more than 12 months [or 24 months in case of cancer] previously); AND

3)    Patient is not a good candidate for or has failed  sphincteroplasty AND

4)    A successful percutaneous test stimulation, defined as at least 50% improvement in symptoms, was performed; AND

5)    Condition is not related to an anorectal malformation (e.g., congenital anorectal malformation; defects of the external anal sphincter over 60 degrees; visible sequelae of pelvic radiation; active anal abscesses and fistulae) or chronic inflammatory bowel disease; AND

6)    Incontinence is not related to another neurologic condition such as peripheral neuropathy or complete spinal cord injury.

Codes Used In This BI:

43647             Laparoscopy surgical; implantation of gastric stimulator electrodes

43648             Laparoscopy revision or removal of gastric stim electrodes

43881             Implantation of gastric neurostimulator electrodes, open

43882             Revision or removal of gastric neurostimulator electrodes, open

64561             Percutaneous implantation neuromuscular electrodes; sacral nerve

64581             Incision for implantation of neurostimulator electrode array; sacral nerve (transforaminal placement)

64585           Revision or removal of peripheral neurostimulator electrode array

64590             Insertion or replacement of peripheral or gastric stimulator

64595             Revision or removal of peripheral or gastric stimulator

1)    Gastric pacing is not covered for:

a)     Treatment of obesity.

b)    Treatment of diabetes

c)     Initial treatment of gastroparesis.

2)    Revision or removal of gastric pacers will only be covered if the original placement was covered or if the original placement met criteria for coverage.

3)    Nonspecific codes are not covered (43659, 43999) since specific codes are available

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