E0737 — Transcutaneous tibial nerve stimulator, controlled by phone application
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- An initial 12-week trial ofpercutaneoustibial nerve stimulation is consideredmedically necessarywhen the following criteria are met (AandB):
- Anyof the following are present for at least 3 months, and not due to a neurological condition:Urinary urge incontinence;orUrinary urgency/frequency;orNon-obstructive urinary retention;and
- Urinary urge incontinence;or
- Urinary urgency/frequency;or
- Non-obstructive urinary retention;and
- Criteria 1and2 below are met:Clinically significant symptoms are present (for example, frequency, or severity impacts ability to work or participate in activities outside of the home);andSymptoms are refractory to, or individual could not tolerate, conservative treatment (for example, medication, pelvic floor muscle exercises, pelvic floor physical exercises with biofeedback, bladder training, or intermittent catheterizations for non-obstructive urinary retention) for at least a sufficient durat [...]
1 Active Policy
ANTHEM-CG-SURG-126 — CG-SURG-126 Tibial Nerve Stimulation
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