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Posterior Tibial Nerve Stimulation

Section: Miscellaneous
Effective Date: July 01, 2018
Revised Date: November 12, 2019
Last Reviewed: November 14, 2019

Description

Posterior or Percutaneous Tibial Nerve Stimulation (PTNS) is an indirect external technique for stimulating the sacral plexus. PTNS was developed as a lessinvasive treatment alternative to traditional sacral root neuromodulation, which has been successfully used in the treatment of urinary dysfunction, but requires the implantation of a permanent device. PTNS, rather, is an office-based type of electrical neuro-modulation that is used for treating voiding dysfunction in patients who have failed behavioral and/or pharmacologic therapies. The principle behind PTNS is that stimulation of specific nerves of the pelvic floor through gentle electrical impulses can alter the activity of the bladder, disrupt the signals that lead to symptoms of urinary dysfunction and improve voiding function and control.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person’s unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Criteria

Coverage is subject to the specific terms of the member’s benefit plan.

PTNS may be considered medically necessary in patients 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 or contraindication to at least two anti-cholinergic drugs prior to the PTNS therapy initiation for the following conditions:
    • Overactive bladder; or 
    • Urge incontinence; or 
    • Frequency-urgency syndrome; or 
    • Non-obstructive urinary retention.

This policy covers an initial treatment regimen of 30-minute weekly sessions for twelve (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 twelve (12) PTNS treatments are not medically necessary when there is any of the following:

  • No documented improvement of OAB symptoms as documented by a voiding diary and/or with urodynamic testing.

PTNS maintenance therapy that goes beyond the initial twelve (12) sessions may be considered medically necessary for the treatment of urinary urgency, urinary frequency, and urge incontinence at a frequency of up to one (1) session every month for up to two (2) years when ALL of the following criteria are met:

  • There is documented completion and tolerance during the initial PTNS therapy (i.e.first twelve (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.

PTNS for any other indication is considered experimental/investigational and, therefore, non-covered because scientific evidence does not support the efficacy and safety.

Procedure Codes

64566

Diagnosis Codes

N32.81 N39.41 N39.46 N39.492 N39.498 R32 R35.0
R39.15

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