HumanaCommercial Clinical Policy

Humana Urinary Bladder Dysfunction Form


PTNS and SNS for UI and OAB

Notes: Coverage for PTNS and SNS for UI and OAB may require additional review according to the member’s individual plan certificate, and treatments considered educational or training in nature are generally not covered.

Indications

(468346) Has the request for PTNS or SNS been reviewed by a medical director? 
(468347) Is the PTNS or SNS treatment for an indication other than UI/OAB? 

Contraindications

(468348) Is the patient prone to excessive bleeding? 
(468349) Does the patient have a pacemaker or implantable defibrillator? 
(468350) Does the patient have neurogenic lower urinary tract dysfunction (NLUTD), such as diabetic neuropathy, multiple sclerosis, or spinal cord injury? 
YesNoN/A
YesNoN/A
YesNoN/A

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Effective Date

12/14/2023

Last Reviewed

NA

Original Document

  Reference



Urinary Bladder Dysfunction

Medical Coverage Policy

Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0407-042

Change Summary: Updated Description, Coverage Determination, Coverage Limitations, References

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

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