REVIEW REQUEST FOR
Sacral Nerve Stimulation (SNS) & Percutaneous
Tibial Stimulation (PTNS) for Urinary
& Fecal Incontinence: Urinary Retention
Provider Data Collection Tool Based on Medical Policy SURG.00117
Policy Last Review Date: 02/05/2015 Policy Effective Date: 04/07/2015
Individual’s Name:
Provider Tool Effective Date: 04/07/2015
Date of Birth:
Insurance Identification Number: Individual’s Phone Number:
Provider ID Number: Ordering Provider Name & Specialty:
Office Address:
Office Phone Number:
Rendering Provider Name & Specialty:
Office Address:
Office Phone Number:
Office Fax Number:
Provider ID Number:
Office Fax Number:
Facility Name:
Facility Address:
Facility ID Number:
Date/Date Range of Service:
Service Requested (CPT if known):
Place of Service: Home Inpatient
Outpatient Other:
Diagnosis Code(s) (if known):
This provider data collection tool is for medical necessity review request for sacral nerve stimulation
(SNS) and percutaneous tibial nerve stimulation (PTNS) in individuals with chronic, refractory urinary and fecal incontinence, as well as urinary retention.
This data collection tool is NOT for review requests for use of SNS for the treatment of neurogenic bladder secondary to spinal cord injury; for information about treatment of neurogenic bladder, see CG-SURG-08 (Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal
Cord Injury) .
For vaginal weight training, injection of periurethral bulking agents, transvaginal radiofrequency bladder neck suspension, and transurethral radiofrequency energy collagen micro-remodeling treatments for urinary incontinence refer to Medial Policy and Clinical Data Submission Tool: SURG.00010 –
Treatments for Urinary Incontinence
Complete SECTION 1 below. as appropriate to the individual, before proceeding to other sections below.
Page 1 of 4

REVIEW REQUEST FOR
Sacral Nerve Stimulation (SNS) & Percutaneous
Tibial Stimulation (PTNS) for Urinary
& Fecal Incontinence: Urinary Retention
Provider Data Collection Tool Based on Medical Policy SURG.00117
Policy Last Review Date: 02/05/2015 Policy Effective Date: 04/07/2015 Provider Tool Effective Date: 04/07/2015
SECTION I
Answer all of the following that apply to the individual:
□ Request is for sacral nerve stimulator therapy for any of the following:
□ Urge incontinence due to a neurologic condition (for example, detrusor hyperreflexia);
□ Stress incontinence and other types of chronic voiding dysfunction due to neurologic conditions
(for example, spinal cord injury, diabetic neuropathy, multiple sclerosis)
□ Chronic pelvic pain
□ Request is for sacral nerve stimulation for fecal incontinence If checked complete the following:
□ Rectal surgery for conditions other than cancer, performed within the past 12 months
□ Rectal surgery for cancer performed within the past 24 months
□ Anorectal malformation (for example, congenital anorectal malformation)
□ Visible sequelae of pelvic radiation
□ Active anal abscesses and fistulae
□ Chronic inflammatory bowel disease (IBD)
□ Peripheral neuropathy
□ Complete spinal cord injury (no motor or sensory function at sacral segments S4-S5)
□ Constipation
□ Request is for percutaneous tibial nerve stimulation (PTNS) treatment of overactive bladder . If checked complete the
following:
□ urinary urgency
□ urinary frequency and urge incontinence
□ stress incontinence
□ non-obstructive urinary retention
□ interstitial cystitis
□ Request is for PTNS is for fecal dysfunction, such as
□ incontinence
□ constipation
□ IBD
□ anal sphincter dysfunction
SECTION 2
Request is for:
□ Sacral nerve stimulation (SNS): Urinary incontinence and retention – If checked, complete Section 3
□ Sacral nerve stimulation: Fecal Incontinence – If checked, complete Section 4
Please proceed to the specific treatment section below and complete ALL of the requested information.
Page 2 of 4

REVIEW REQUEST FOR
Sacral Nerve Stimulation (SNS) & Percutaneous
Tibial Stimulation (PTNS) for Urinary
& Fecal Incontinence: Urinary Retention
Provider Data Collection Tool Based on Medical Policy SURG.00117
Policy Last Review Date: 02/05/2015 Policy Effective Date: 04/07/2015 Provider Tool Effective Date: 04/07/2015
SECTION 3: Sacral nerve stimulation (SNS): Urinary incontinence and retention (Please check all of the following that apply to the individual
□ Request is for placement of a temporary sacral nerve stimulator for an individual with urinary urge
incontinence and urinary urgency/frequency
□ Individual has had a trial period of sacral nerve neuromodulation with percutaneous nerve
stimulation
□ Individual has had a trial period of sacral nerve neuromodulation with a temporarily
implanted lead
□ The individual has experienced urge incontinence for a minimum of 12 months duration that is not due to a neurologic condition and has resulted in significant disability (frequency or severity impacts ability to work or participate in activities outside of the home)
□ The individual is refractory or cannot tolerate a minimum of 12 consecutive months of
conservative treatments (exercises, medication);
□ The individual is an appropriate surgical candidate for permanent implantation.
□ Request is for placement of a temporary sacral nerve stimulator for an individual with
non-obstructive urinary retention
□ Individual has had a trial period of sacral nerve neuromodulation with percutaneous nerve stimulation
□ Individual has had a trial period of sacral nerve neuromodulation with a temporarily implanted lead
□ Individual is an appropriate surgical candidate for permanent implantation
□ Individual has experienced urinary retention for a minimum of 12 months duration that is not
due to a neurologic condition and has resulted in significant disability (frequency or severity impacts ability to
work or participate in activities outside of the home)
□ Individual is refractory or could not tolerate a minimum of 12 consecutive months of pharmacotherapy
□ Intermittent catheterizations have failed or are not well tolerated, following a trial of 12 consecutive months.
□ Request is for placement of a permanent sacral nerve stimulator for an individual with refractory
urge incontinence, urge/frequency incontinence or non-obstructive urinary retention
□ Individual is an appropriate surgical candidate for permanent implantation.
□ Individual has had a successful trial of the temporary sacral nerve stimulator (Check all that apply)
□ Urinary retention: at least a 50% reduction in catheter volume/catheterization
□ Urinary urge incontinence: At least 50% reduction in one of the following: daily incontinence
episodes, severity of the episodes or the number of pads/diapers used per day.
□ Urinary urge/frequency: At least 50% reduction in one of the following: number of voids daily,
volume per void and frequency per void.
□ Other (please describe):____________________
Page 3 of 4

REVIEW REQUEST FOR
Sacral Nerve Stimulation (SNS) & Percutaneous
Tibial Stimulation (PTNS) for Urinary
& Fecal Incontinence: Urinary Retention
Provider Data Collection Tool Based on Medical Policy SURG.00117
Policy Last Review Date: 02/05/2015 Policy Effective Date: 04/07/2015 Provider Tool Effective Date: 04/07/2015
SECTION 4: Sacral Nerve stimulation: Fecal Incontinence (Please check all of the following that apply to the individual)
□ Request is for placement of a temporary sacral nerve stimulator for the treatment of fecal
incontinence
□ Individual has incontinent episodes averaging greater than or equal to 2 per week
or 6 consecutive months, except after vaginal childbirth when the symptoms must persist
for 12 consecutive months
□ Individual’s medical record shows failure of or intolerance to conventional therapy
(for example, dietary modification , the addition of bulking and pharmacologic treatment)
□ Individual is an appropriate surgical candidate
□ Other (please describe): _________________________
□ Request is for placement of a permanent sacral nerve stimulator for the treatment of fecal
incontinence
□ Individual has met the criteria above for a temporary sacral nerve stimulator
□ Individual is an appropriate surgical candidate for permanent implantation
□ Individual has had a successful trial of the temporary sacral nerve stimulator
□ Individual shows at least a 50% improvement in symptoms with the temporary sacral nerve
stimulator
□ Other (please describe): ______________
This request is being submitted:
Pre-Claim
Post–Claim. If checked, please attach the claim or indicate the claim number
I attest the information provided is true and accurate to the best of my knowledge. I understand that the health plan or its designees may perform a routine audit and request the medical documentation to verify the accuracy of the information reported on this form.
Name and Title of Provider or Provider Representative Completing
Form and Attestation (Please Print)*
Date
*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted.
Anthem UM Services, Inc., a separate company, is the licensed utilization review agent that performs utilization management services on behalf of your health benefit plan or the administrator of your health benefit plan.
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