CurrentCentenePolicy CP.MP.133

Posterior Tibial Nerve Stimulation for Voiding Dysfunction

Defines medical necessity criteria for percutaneous posterior tibial nerve stimulation (PTNS) for treatment of overactive bladder (OAB), including initial and maintenance therapy, and states that implantable tibial nerve stimulation is not supported by evidence. Provides applicable CPT coding guidance.

Policy Summary

PayerCentene

PolicyPosterior Tibial Nerve Stimulation for Voiding Dysfunction

Policy CodePolicy CP.MP.133

Change TypeCoding and criteria wording updates (annual reviews)

Effective Date

Next Review Date

Key ActionProvider must document diagnosis of OAB, prior failure of conservative management (behavioral therapies or medications used with intent to treat OAB) unless contraindicated or not desired, and that treatment will follow 30-minute weekly sessions for 12 weeks; document significant improvement after initial 12 sessions to justify maintenance therapy.

SourceLink

POLICY UPDATE CHANGES

Replaced 'investigational' language with 'insufficient evidence to support' in statements regarding use beyond 12 months and implantable devices.

Updated CPT coding guidance to list 64566 as supporting medical necessity and T-codes (0587T–0590T) as not supporting medical necessity.

1Covered CPT for PTNS

4CPT codes not supported

12Initial weekly sessions (weeks)

Coverage Summary

Scope: This policy (Policy Number CP.MP.133, status CURRENT, last review 07/25) defines medical necessity criteria for percutaneous posterior tibial nerve stimulation (PTNS) to treat overactive bladder (OAB). Coverage stance: covered_with_criteria. Initial therapy is medically necessary when all criteria are met, including a diagnosis of OAB, failure of conservative medical management (e.g., behavioral therapies or medications used with intent to treat OAB, unless contraindicated or not desired), and provision of the standard initial regimen of 30-minute weekly sessions for 12 weeks. Maintenance (once-monthly) treatments are medically necessary for patients who experience significant improvement after the 12 initial treatments. The policy states there is insufficient evidence to support use of PTNS beyond 12 months and that implantable tibial nerve stimulation devices are not supported by the published peer-reviewed literature.

Quick facts / Key thresholds

Standard initial PTNS regimen30-minute weekly sessions for 12 weeks

Maintenance frequency (policy default)Once-monthly maintenance treatments if significant improvement after the initial 12 treatments; frequency may be individualized based on symptom return

Stimulation parameters (informational)Current level 0.5 to 9 mA at 20 Hz for 30 minutes (typical)

Covered CPT code (PTNS)64566

CPT codes not supported (implantable systems)0587T, 0588T, 0589T, 0590T

Initial weekly sessions (headline stat)12 weeks

Medical-Necessity Criteria

Initial Therapy - Medical Necessity

PTNS is medically necessary when ALL of the following are met:

Initial PTNS medical necessity

Diagnosis of overactive bladder (OAB)
Conservative management failure: Failure of conservative medical management (e.g., behavioral therapies such as bladder training or pelvic floor muscle training, or pharmacotherapy with oral medications used with the intent to treat OAB), unless conservative management is not desired or is medically contraindicated
Includes behavioral therapies and pharmacotherapy examples per policy
Treatment regimen: Service is provided in accordance with the standard treatment regimen of 30-minute weekly sessions for 12 weeks30-minute weekly x12

Coding

CPT codes that support medical necessityCPTCovered

64566

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

CPT codes that do not support medical necessity (implantable neurostimulation systems / related services)CPTNot Covered

0587T	Percutaneous implantation or replacement of integrated single device neurostimulation system for bladder dysfunction including electrode array and receiver or pulse generator, including analysis, programming and imaging guidance when performed, posterior tibial nerve
0588T	Revision or removal of percutaneously placed integrated single device neurostimulation system for bladder dysfunction including electrode array and receiver or pulse generator, including analysis, programming, and imaging guidance when performed, posterior tibial nerve
0589T	Electronic analysis with simple programming of implanted integrated neurostimulation system for bladder dysfunction, posterior tibial nerve, 1-3 parameters
0590T	Electronic analysis with complex programming of implanted integrated neurostimulation system for bladder dysfunction, posterior tibial nerve, 4 or more parameters

Billing note: CPT code 64566 supports percutaneous PTNS claims when the medical necessity criteria are met; implantable-device CPT codes 0587T–0590T and related services are identified in this policy as not supporting medical necessity and should not be billed for percutaneous PTNS.

Provider Actions / Documentation & Billing

Prior Authorization

Medical necessity documentation for PTNS

Providers must document the diagnosis of overactive bladder (OAB), prior failure of conservative management (behavioral therapies such as bladder training or pelvic floor muscle training, or medications used with intent to treat OAB) unless such management is contraindicated or not desired, and that treatment will follow the standard regimen of 30-minute weekly sessions for 12 weeks. This documentation is required for prior authorization/medical necessity determination for percutaneous PTNS.

64566

Documentation Required

Maintenance therapy justification

Document that the patient experienced significant symptomatic improvement after the initial 12 weekly PTNS treatments and an individualized maintenance plan (maintenance frequency may be once-monthly or vary based on symptom return) to justify ongoing coverage.

Background, Evidence & Definitions

Background: Posterior tibial nerve stimulation (PTNS) is a minimally invasive neuromodulation technique that modulates bladder function by percutaneous stimulation of the posterior tibial nerve just above the ankle. Typical initial treatment consists of 12 weekly 30-minute sessions, with responders often showing improvement after six to eight sessions; some patients require maintenance sessions to sustain benefit. Evidence supports short- and medium-term symptom reduction for OAB, but evidence is limited or insufficient to support implantable tibial nerve stimulators and routine PTNS use beyond 12 months.

Evidence

Definitions

Overactive bladder (OAB)Voiding dysfunction symptom complex including urinary frequency, urgency, urge incontinence, and nocturia.

PTNSPosterior tibial nerve stimulation; percutaneous stimulation of the posterior tibial nerve to modulate bladder function

Medicare Determinations

Name	Number	Effective Date	Type
Posterior tibial nerve stimulation for voiding dysfunction	L33396	2015-10-01 (revised 2019-10-24)	LCD

Revision History

07/25wording/background updateLatest

Replaced 'investigational' language with 'insufficient evidence to support' in statements regarding use beyond 12 months and implantable devices; multiple annual reviews updated wording, background, and clarified examples of behavioral therapies and medication wording under Criteria I.B.

07/25coding updateLatest

Updated CPT coding guidance: listed 64566 as supporting medical necessity and T-codes (0587T–0590T) as not supporting medical necessity; coding and descriptions reviewed and updated during annual review.