Sacral nerve stimulation is covered under Medicare National Coverage Determination 230.18, administered by Noridian for California patients. Medicare covers SNM for urinary urge incontinence, urgency-frequency syndrome, and non-obstructive urinary retention.

Medicare Requirements

• Patient must be refractory to conventional therapy (not a specific number of medications)
• Test stimulation showing ≥50% improvement, documented via voiding diary
• Ability to maintain bladder diary data

Medicare Exclusions

• Pure stress urinary incontinence
• Urinary obstruction
• Diabetes with peripheral neuropathy

PTNS is also covered by Medicare under the Noridian LCD for California for urgency, frequency, and urge incontinence.

Aetna considers sacral nerve stimulation medically necessary for urge urinary incontinence, urgency-frequency syndrome, and non-obstructive urinary retention under Clinical Policy Bulletin 0223.

Aetna Coverage Requirements

• Trial stimulation required with ≥50% decrease in symptoms as threshold
• Non-obstructive urinary retention must persist for at least 6 months
• Failure of conservative therapy (behavioral and/or pharmacological)
• Permanent implant covered when trial criteria are met

Aetna is a major California insurer accepted at all six of our San Diego area locations. Prior authorization is typically required.

UnitedHealthcare covers sacral nerve stimulation as a safe and effective minimally invasive therapy for urinary incontinence, urinary retention, urgency, frequency, and fecal incontinence.

UnitedHealthcare Requirements

• Trial stimulation period of 3–7 days required to determine permanent device eligibility
• Appropriate indications: urge incontinence, urgency-frequency, non-obstructive retention
• Documentation of prior conservative treatment failure
• Prior authorization required for California members

UHC (AARP Medicare Complete and commercial) is accepted at our San Diego locations. Our team submits prior authorization documentation on your behalf.

Anthem Blue Cross California covers sacral nerve neuromodulation/stimulation under Clinical Guideline CG-SURG-95, aligned with the AUA and SUFU guidelines supporting SNM as a third-line intervention for severe, refractory overactive bladder.

Anthem Requirements

• Refractory OAB — not adequately controlled by behavioral therapy and/or medications
• Successful trial stimulation demonstrating significant symptom improvement
• Approved FDA devices only (InterStim, Axonics) for covered indications
• Prior authorization required for California members

Anthem Blue Cross is one of the largest California insurers. Blue Shield of California is a separate entity with similar coverage policies.

Cigna covers sacral nerve stimulation under Medical Coverage Policy mm_0404 for FDA-approved devices including the Medtronic InterStim Sacral Nerve Stimulation Therapy System and the Axonics Sacral Neuromodulation System.

Cigna Coverage Criteria

• Diagnosis of urge incontinence, urgency-frequency syndrome, or non-obstructive urinary retention
• Inadequate response to or intolerance of conservative treatments
• Successful trial stimulation with documented symptom improvement
• Prior authorization required

Cigna is accepted at California Bladder San Diego locations. Our team handles prior authorization paperwork from submission through approval.

Blue Shield of California and Health Net generally cover sacral neuromodulation and PTNS for appropriate OAB and urge incontinence indications when clinical criteria and prior authorization requirements are met.

We Also Accept

• Medicare Advantage plans (plan-specific criteria apply)
• Covered California marketplace plans
• CHG, SCMG, Primary Care Associates
• Many other California plans — call to verify

Call (858) 571-3630 to verify your specific California plan's coverage.

Medi-Cal, California's Medicaid program, covers sacral nerve stimulation for medically appropriate indications following CMS guidance. Most Medi-Cal enrollees receive care through managed care plans (Molina, Health Net Medi-Cal, etc.) which each have their own prior authorization processes.

Medi-Cal Coverage Key Points

• Coverage follows CMS/Medicare guidance on appropriate indications
• Prior authorization required — submitted through your managed care plan
• Diagnosis documentation of OAB, UUI, or urgency-frequency required
• Evidence of conservative treatment failure required
• Fee-for-service Medi-Cal: claims processed through DHCS

Call (858) 571-3630 — our team verifies Medi-Cal managed care plan requirements specific to your plan before your first visit.

TRICARE covers sacral neuromodulation for eligible active duty military, retirees, and their covered family members when medically necessary criteria are met. TRICARE follows similar evidence-based criteria to commercial plans and Medicare.

TRICARE Coverage Details

• Eligible under TRICARE Prime, TRICARE Select, and TRICARE for Life
• TRICARE for Life (retired beneficiaries with Medicare) — Medicare is primary, TRICARE secondary
• Prior authorization typically required for non-active-duty members
• Referral may be required depending on plan type
• SNM indicated for UUI, OAB, urgency-frequency, non-obstructive retention

Many San Diego area patients have TRICARE coverage through nearby military installations. Call (858) 571-3630 to verify your specific TRICARE plan and referral requirements.

VA Community Care Program: Veterans may receive bladder treatment through the VA Community Care Network when their local VA facility cannot provide timely access or the service is unavailable locally. California Bladder can work with veterans through this program.

CHAMPVA: The Civilian Health and Medical Program of the Department of Veterans Affairs covers eligible dependents (spouses and children) of veterans who are permanently and totally disabled due to a service-connected disability, or who died from a service-connected condition.

VA & CHAMPVA Key Points

• VA Community Care: Veteran must be eligible for VA health care and receive authorization from VA prior to community care visit
• CHAMPVA: Covers medically necessary SNM and PTNS for eligible dependents; prior authorization required for procedures
• Both programs require standard medical necessity documentation — diagnosis, failed conservative treatment, appropriate indication
• Our team assists with VA authorization paperwork and CHAMPVA claim documentation