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Coverage criteria policies

Percutaneous tibial nerve stimulation (PTNS) for overactive bladder

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for more than 12 PTNS treatment sessions.

Coverage

PTNS is generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

Percutaneous tibial nerve stimulation (PTNS) beyond the initial 12 treatments is covered for the treatment of overactive bladder and associated symptoms of urinary frequency, urge incontinence, and urinary urgency, when all of the following are present:

  1. Symptoms have been present at least 12 months and have resulted in a significant limitation of activities of daily living.
  2. Active urinary tract infections and anatomical abnormalities of the lower urinary tract have been excluded as a source of urinary dysfunction.
  3. Conservative treatment which may include: Behavioral treatments such as biofeedback, fluid management, pelvic floor exercises, timed voids, etc. and/or pharmacotherapies (at least 2 different anti-cholinergic drugs or a combination of an anti-cholinergic and a tricyclic anti-depressant) have been tried for at least 3 months and have failed.
  4. Documentation that member has had a decrease in symptoms since starting PTNS treatment.

Indications that are not covered

PTNS for the treatment of all other indications, including stress incontinence, is not covered.

Definitions

Percutaneous tibial nerve stimulation (PTNS) is a 30 minute office based treatment for overactive bladder and associated symptoms. A needle electrode is inserted near the tibial nerve, which carries electric impulses from a hand-held stimulator to the sacral plexus. Currently, the Urgent PC® Neuromodulation System and the NURO™ System are the only FDA-cleared systems available to provide PTNS treatment.

If available, codes for a procedure, device or diagnosis are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all inclusive.

Codes

Description

64566

Posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. ECRI Institute. (2012). Posterior Tibial Nerve Stimulation for Treating Urge Incontinence. Plymouth Meeting, PA. ECRI Institute.
  2. Gormley, E. A., Lightner D. J., Faraday, M., & Vasavada, S. P., American Urological Association, Society of Urodynamics, Female Pelvic Medicine. (2014). Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline amendment. The Journal of Urology, 193(5), 1572-1580.
  3. Hayes, Inc. Hayes Medical Technology Directory Report. Percutaneous Tibial Nerve Stimulation for the Treatment of Lower Urinary Tract Dysfunction. Lansdale, PA: Hayes, Inc. December, 2014. Reviewed November 2017.
  4. Lukacz, E.S. Treatment of urgency incontinence/overactive bladder in women. In: UpToDate, Brubaker, L. & Schmader K. E. (Eds), UpToDate, Waltham, MA (Accessed on September 18, 2018).
  5. Stewart F, Gameiro OLF, El Dib R, Gameiro MO, Kapoor A, Amaro JL. Electrical stimulation with non-implanted electrodes for overactive bladder in adults. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD010098. DOI: 10.1002/14651858.CD010098.pub3.

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Policy activity

  • 08/30/2011 - Date of origin
  • 11/01/2018 - Effective date
Review date
  • 08/2018
Revision date
  • 10/10/2018

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