0587T — Perq impltj/rplcmt isdns ptn
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Documented diagnosis of OAB.
- Documentation of failure of conservative management (behavioral therapies and/or oral medications) or documentation that such management is contraindicated or declined by the patient.
- Documentation of adherence to the initial regimen (30-minute weekly sessions × 12) including dates and session duration.
- For maintenance therapy, documentation of significant symptom improvement after the initial 12 treatments.
Key Coverage Criteria
- Posterior tibial nerve stimulation (PTNS) for treatment of overactive bladder (OAB) syndrome and associated symptoms, including urinary urgency, urinary frequency, and urge urinary incontinence.
- Diagnosis of overactive bladder (OAB).
- Failure of conservative medical management (e.g., bladder training, pelvic floor muscle training, or oral pharmacotherapy) unless such management is not desired or is medically contraindicated.
- Initial PTNS treatment delivered as 30-minute weekly sessions for 12 weeks (standard treatment regimen).
- Once-monthly maintenance PTNS is medically necessary for patients who experience significant improvement in OAB symptoms after the initial 12 treatments; maintenance frequency may vary with return of symptoms.
- PTNS as a minimally invasive neuromodulation technique to modulate the sacral nerve plexus via stimulation of the posterior tibial nerve for treatment of bladder dysfunction (controls bladder function).
1 Active Policy
AMBETTER-CP.MP.133 — Posterior Tibial Nerve Stimulation for Voiding Dysfunction
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