Point32 Percutaneous Posterior Tibial Nerve Stimulation (PTNS) Form

Harvard Pilgrim HealthCare Medical Policy

Percutaneous Posterior Tibial Nerve Stimulation (PTNS)

Subject: Percutaneous Posterior Tibial Nerve Stimulation (PTNS)

Background: 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.

Authorization: Prior authorization is required for all percutaneous posterior tibial nerve stimulation requested for members enrolled in commercial (HMO, POS, and PPO) products.

Policy and Coverage Criteria:

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.
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).
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 every 1 to 2 months for no more than three years.

Exclusions:

The Plan considers PTNS as experimental and investigation for all other indications. In addition, The Plan does not cover:

• If a 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