CommercialPrior AuthMedium impact
Fecal Incontinence (CPB 0611, reviewed 2026-09-23)
Aetna·Gastroenterology, General Surgery, PM&R (Physical Medicine & Rehab)·Medical Policy
We identified it
Sep 30, 2026
Summary
Aetna updated its fecal incontinence policy (CPB 0611, reviewed 2026-09-23) establishing medical necessity criteria for diagnostic tests, conservative treatments, and invasive procedures. The policy requires a 3-month trial of 2+ traditional treatments before authorizing surgical interventions like sphincter repair, colostomy, sacral nerve stimulation, or the Acticon Neosphincter. Multiple emerging treatments remain experimental/investigational including anal slings, graciloplasty, injectable bulking agents, magnetic sphincter augmentation, and regenerative medicine approaches.
Action Required
Immediately: Billing team must implement prior authorization requirements for sacral nerve stimulation procedures (CPT 64561, 64581, 64590, 64595) to verify 3-month trial of conservative treatments before approval. Update authorization templates to require documentation of failed/contraindicated biofeedback, dietary management, pharmacotherapy, and strengthening exercises. Flag these CPT codes in billing software: Stop processing claims for experimental codes (0587T, 0588T, 0589T, 0590T for posterior tibial nerve stimulation; 0963T, 1001T, 11950-11954 for injectable/regenerative treatments; 64566 for posterior tibial stimulation; graciloplasty; magnetic sphincter augmentation) without explicit prior authorization denial authority. For surgical sphincter repair (46750, 46751, 46760, 46761), colostomy, and Acticon Neosphincter procedures: require documentation showing severe fecal incontinence (involuntary loss weekly or more frequent) and failure of conservative treatments. Update encounter forms to prompt providers to document conservative treatment history. Compliance failure will result in claim denials for non-authorized procedures.