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: 08/14/2014
Policy Effective Date: 10/14/2014
Provider Tool Effective Date: 10/08/2013
Individual’s Name:
Date of Birth:
Insurance Identification Number:
Individual’s Phone Number:
Ordering Provider Name & Specialty:
Provider ID Number:
Office Address:
Office Phone Number:
Office Fax Number:
Rendering Provider Name & Specialty:
Provider ID Number:
Office Address:
Office Phone Number:
Office Fax Number:
Facility Name:
Facility ID Number:
Facility Address:
Date/Date Range of Service:
Place of Service:
Service Requested (CPT if known):
Outpatient
Home
Inpatient
Other:
Diagnosis Code(s) (if known):
**** For other treatments of urinary incontinence please refer to Clinical Data Submission Tool:
SURG.00010 – Treatments for Urinary Incontinence ****
Please check all that apply to the individual:
SACRAL NERVE STIMULATION (SNS): URINARY INCONTINENCE & RETENTION
Please respond to this section prior to completing the appropriate temporary or permanent sacral nerve stimulator
placement for urinary incontinence & retention questions below.
Individual has urge incontinence due to a neurologic condition (e.g., detrusor hyperreflexia)
Individual has positive peripheral nerve evaluation test and urinary urge incontinence or urinary
urgency/frequency unrelated to a neurologic condition
Individual has stress incontinence or another type of chronic voiding dysfunction due to neurologic conditions
(for example, spinal cord injury, diabetic neuropathy, multiple sclerosis)
Individual has positive peripheral nerve evaluation test and non-obstructive urinary retention
Request is to treat individual’s chronic pelvic pain
Other (please describe):
Page 1 of 3
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: 08/14/2014
Policy Effective Date: 10/14/2014
Provider Tool Effective Date: 10/08/2013
Request is for placement of a temporary sacral nerve stimulator (Check all that apply)
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)
Individual is refractory or could not tolerate a minimum of 12 consecutive months of conservative treatments
(exercises, medication)
Individual is an appropriate surgical candidate for permanent implantation.
Individual is refractory or could not tolerate a minimum of 12 consecutive months of pharmacotherapy
Intermittent catheterizations have failed or are not well tolerated after a trial of 12 consecutive months.
Other (please describe):
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 (Check all that apply)
Individual has had a successful trial of the temporary sacral nerve stimulator and is an appropriate surgical
candidate for permanent implantation. Successful trial defined as: (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):
Other (please describe):
SACRAL NERVE STIMULATION: FECAL INCONTINENCE
Please respond to this section prior to completing the appropriate temporary or permanent sacral nerve stimulator
placement for fecal incontinence questions below.
Rectal surgery for conditions other than cancer, performed within the past 12 months
Rectal surgery for cancer performed within the past 24 months
An 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 the sacral segments S4-S5);
Constipation.
Other (please describe):
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 for 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 had a successful trial of the temporary sacral nerve stimulator and is an appropriate surgical
candidate for permanent implantation. Successful trial is defined as: (Check all that apply)
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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: 08/14/2014
Policy Effective Date: 10/14/2014
Provider Tool Effective Date: 10/08/2013
Individual shows at least a 50% improvement in symptoms with a temporary sacral nerve stimulator
Other (please describe):
Other indication not specified above. (please describe):
PERCUTANEOUS TIBIAL NERVE STIMULATION (PTNS)
Request is for percutaneous tibial nerve stimulation for: (check all that apply)
Individual has an overactive bladder symptoms such as urinary urgency, urinary frequency, urge incontinence
stress incontinence, non-obstructive urinary retention, or interstitial cystitis
Individual has a fecal dysfunction such as incontinence, IBD or anal sphincter dysfunction
Other (please describe):
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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