Criteria
PTNS may be considered medically necessary in individuals who meet the following criteria:
- Documented failure with treatment outcomes for each of the following: pelvic muscle retraining, bladder training, prompted voiding; and
- Documented intolerance, contraindication, or failure with treatment outcomes (after at least a four (4) week trial) to at least two (2) anti-cholinergic drugs prior to the PTNS therapy initiation for the following conditions:
- Overactive bladder; or
- Urge incontinence; or
- Frequency-urgency syndrome; or
- Neurogenic bladder dysfunction.
This policy covers an initial treatment regimen of 30-minute weekly sessions for 12 weeks of PTNS for the treatment of overactive bladder (OAB) symptoms when there is documented failure, contraindication or an intolerance to first and second line urological, medical management for the above covered conditions as stated in the policy.
More than 12 PTNS treatments are considered not medically necessary when there is no documentation of improvement of symptoms (50% reduction or greater) of urinary frequency, nocturia, and/or urinary urgency.
PTNS maintenance therapy that goes beyond the initial 12 sessions may be considered medically necessary at a frequency of up to one (1) session every month for up to a maximum of three (3) years when ALL of the following criteria are met:
- There is documented completion and tolerance during the initial PTNS therapy (i.e. first 12 sessions of PTNS); and
- There is a documented improvement of the symptoms (50% reduction or greater) of urinary frequency, nocturia, and/or urinary urgency during the initial PTNS therapy.
The maximum lifetime number of PTNS treatments will be 48 total. PTNS treatments that exceed the frequency guidelines listed on the policy are considered not medically necessary.
PTNS not meeting the criteria as indicated in this policy is considered not medically necessary, including but not limited to fecal incontinence.
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