Posterior or Percutaneous Tibial Nerve Stimulation (PTNS) is an indirect external technique for stimulating the sacral plexus. PTNS was developed as a less-invasive treatment alternative to traditional sacral 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 individuals 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.
PTNS may be considered medically necessary in individuals who meet the following criteria:
This policy covers an initial treatment regimen of 30-minute weekly sessions for 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 12 PTNS treatments are considered not medically necessary when there is no documentation of improvement of symptoms (50% reduction or greater) of urinary frequency, nocturia, and/or urinary urgency.
PTNS maintenance therapy that goes beyond the initial 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:
PTNS is considered experimental/investigational and therefore, non-covered because the safety/and or effectiveness of this service cannot be established by the available published peer reviewed literature for all other indications, including but not limited to fecal incontinence.
64566 |
0587T |
0588T |
0589T |
0590T |
|
|
Refer to Medical Policy S-131, Sacral Nerve Neuromodulation/Stimulation, for additional information.
Refer to Medical Policy Z-7, Electrical Nerve Stimulation, for additional information.
Covered Diagnosis Codes for procedure codes 64566, 0587T, 0588T, 0589T, and 0590T
N31.0 |
N31.1 |
N31.2 |
N31.8 |
N31.9 |
N32.81 |
N39.41 |
N39.46 |
N39.492 |
N39.498 |
R32 |
R35.0 |
R35.81 |
R35.89 |
R39.15 |
|
|
|
|
|
|
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 or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you need these services, contact the Civil Rights Coordinator.
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475
, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697
(TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association. Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York]. All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
