Posterior or percutaneous tibial nerve stimulation (PTNS) is an external, non-surgical form of neuromodulation aimed at stimulating the nerves that supply the bladder and pelvic floor to treat symptoms of overactive bladder (OAB). It is a simple form of neuromodulation that does not involve a permanently implanted device and therefore, can be performed in an office-based setting. PTNS should not be performed as first line therapy for patients with OAB.

Clinical Guideline Coverage Criteria

The Plan uses guidance from the Centers for Medicare and Medicaid Services (CMS) and MassHealth for coverage determinations for its Dual Product Eligible plan Members. CMS National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Local Coverage Articles (LCAs) and documentation included in the Medicare manuals and MassHealth Medical Necessity Determinations are the basis for coverage determinations where available. For Tufts Health One Care plan Members, the following criteria is used:

Posterior Tibial Nerve Stimulation for voiding Dysfunction LCD L33396

Percutaneous Posterior tibial nerve stimulation (PTNS) for the treatment of non-neurogenic urinary dysfunction including overactive bladder symptoms may be considered medically necessary, up to a maximum of 12 weeks when ALL of the following conditions are met:

1. A specialist (e.g., urologist or urogynecologist) confirms the Member is a good candidate for PTNS with documentation that supports the need for PTNS therapy initiation; and
2. Urinary dysfunction has persisted for at least 12 months and the condition has resulted in moderate to severe OAB symptoms (e.g., urinary urgency, frequency, urge incontinence); and
3. Failure of other conservative treatments of at least 8 to 12 weeks to control symptoms (e.g., pelvic floor physical therapy, prompted voiding); and
4. Failure, contraindication, or intolerance to two appropriate medications (e.g., pharmacotherapy with alpha blockers and cholinergic) for at least 4 weeks duration prior to the PTNS therapy

Note: Treatment consists of an initial course of one 30-minute session per week for a duration of 12 weeks. Maintenance therapy may be medically necessary when there is documented evidence of at least 50% improvement in incontinence symptoms (e.g., decreased urinary urgency, frequency, and/or incontinence) after the initial 12 sessions. Continued coverage may be allowed at a frequency of 1 session every 1 to 2 months for no more than three years

Limitations

• In addition, The Plan does not cover the following:
• If the member has no improvement in overactive bladder symptoms after 12 PTNS treatments, continued treatment is considered not medically necessary
• Percutaneous tibial nerve stimulation is considered not medically necessary for all other indications, including but not limited to neurogenic bladder dysfunction, fecal incontinence chronic pelvic pain, constipation, and voiding dysfunction secondary to a neurological condition
• The Plan will not cover implantable tibial nerve stimulation as this is considered not medically necessary

Codes