This checklist was developed by Stephanie Van Zandt, M.D. (see story, p. 1).[1]
Indication Checklist for Sacral Nerve Stimulation
Patient Name: ________________________________________
DOB: ________________________________________________
Documentation of the following required:
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Urinary urge incontinence
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Urgency-frequency syndrome
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Urinary retention (nonobstructive)
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Fecal incontinence (must document a 2-3 week test stimulation trial)
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Documentation of a weakened but structurally intact anal sphincter
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Effect of incontinence/retention on patient’s ability to work or perform activities
Pre-procedure requirements. Include documentation of the following unless contraindicated:
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Behavioral therapy failed
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Medications
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List meds trialed: _________________________________________________________
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Surgical corrective therapy
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Patient voiding or fecal incontinence diary kept after test stimulation (must demonstrate 50% or > improvement to support subsequent implantation). Patient must have adequate ability to record diary data
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Biofeedback failed for fecal incontinence
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Dietary management trial for fecal incontinence
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Strengthening therapy trial for fecal incontinence
Sacral nerve stimulation for the following conditions is not considered medically necessary:
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Stress incontinence, urinary obstruction and specific neurologic diseases with associated secondary manifestations
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Diathermy for fecal incontinence is a contraindication
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Patients who are unable to operate the neurostimulator are not candidates for SNS for fecal incontinence
Procedure Date: ____________________________
Physician Signature: _________________________
Date/Time: _________________________________