Fecal Incontinence (CPB 0611, reviewed 2026-02-25)

By February 25, 2026, the billing team must: (1) Update claim submission software to require documentation of 3-month trial of 2 or more conservative treatments (biofeedback CPT 90912/90913, bowel training, diet modification, pharmacotherapy) before approving CPT codes 46750, 46751, 46760, 46761 (sphincter repair/colostomy) and 64561, 64581, 64590, 64595 (sacral nerve stimulation devices); (2) Configure system to DENY claims for experimental/non-covered procedures including CPT 0963T (injectable bulking agents), 1001T (autologous muscle cell therapy), 11950-11954 (subcutaneous filling materials), 64566 (posterior tibial stimulation), 0587T-0590T (posterior tibial nerve stimulation), and all regenerative medicine codes; (3) Create prior authorization workflow requiring verification of inadequate response to conservative treatments and documentation of weak but structurally intact anal sphincter before approving CPT 64561/64581 (sacral nerve stimulation trial electrode); (4) Configure automatic approval rules for CPT 64590/64595 only when documentation shows ≥50% improvement from temporary percutaneous electrode trial over ≥48 hours; (5) Add policy reference CPB 0611 to all fecal incontinence claim edits and denial templates. Providers should receive updated guidance on covered diagnostic codes (anorectal manometry, ultrasonography, sensory testing per CPB 0616) and conservative treatment documentation requirements. Failure to implement these edits will result in claim denials and member appeals for non-covered procedures.