CurrentConnectiCarePolicy MG.MM.ME.67

Posterior Tibial Nerve Stimulation for Voiding Dysfunction

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This policy governs medical-necessity and coverage criteria for percutaneous posterior tibial nerve stimulation (PTNS) for overactive bladder and related voiding symptoms in ConnectiCare members. It also identifies excluded indications and noncovered implantable and wearable tibial nerve stimulation devices.

Policy Summary

PayerConnectiCare

PolicyPosterior Tibial Nerve Stimulation for Voiding Dysfunction

Policy CodePolicy MG.MM.ME.67

Change TypeMaterial update

Effective DateMay 8, 2026

Next Review DateN/A

Key ActionSubmit clinical evidence showing that the member meets the criteria and has been evaluated by an appropriate specialist who determined the member is a candidate for office-based PTNS.

SourceLink

POLICY UPDATE CHANGES

Revi, formerly known as the RENOVA iStim system, was added as an example of implantable tibial nerve stimulation considered not medically necessary.

Wearable PTNS device examples, including the Vivally System and Zida Wearable Neuromodulation System, are listed as not medically necessary due to insufficient evidence of therapeutic value.

Failure or intolerance of behavioral or medical management is no longer required as a prerequisite for PTNS.

In-office treatment sessions and voiding diary prerequisites were removed from the policy.

12Initial weekly treatment sessions

30 min

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CurrentConnectiCarePolicy MG.MM.ME.67

Posterior Tibial Nerve Stimulation for Voiding Dysfunction

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Policy Summary

PayerConnectiCare

PolicyPosterior Tibial Nerve Stimulation for Voiding Dysfunction

Policy CodePolicy MG.MM.ME.67

Change TypeMaterial update

Effective DateMay 8, 2026

Next Review DateN/A

Key ActionSubmit clinical evidence showing that the member meets the criteria and has been evaluated by an appropriate specialist who determined the member is a candidate for office-based PTNS.

SourceLink

POLICY UPDATE CHANGES

Revi, formerly known as the RENOVA iStim system, was added as an example of implantable tibial nerve stimulation considered not medically necessary.

Wearable PTNS device examples, including the Vivally System and Zida Wearable Neuromodulation System, are listed as not medically necessary due to insufficient evidence of therapeutic value.

Failure or intolerance of behavioral or medical management is no longer required as a prerequisite for PTNS.

In-office treatment sessions and voiding diary prerequisites were removed from the policy.

12Initial weekly treatment sessions

30 min

Duration of each initial PTNS session

≥50%Required improvement for continuation

26Annual maximum continued treatments

64566Applicable PTNS procedure code

PTNS Medical Necessity Criteria

Initial PTNS treatment

Covered when all of the following are met:

Initial office-based PTNS medical necessity

Specialist evaluation: The member has been evaluated by an appropriate specialist.
Specialist determination: The specialist has determined that the member is a candidate for PTNS.

Continuation therapy

Continuation is covered when all of the following are met:

Continuation PTNS

Completion of initial regimen: The member completed the initial regimen of one 30-minute PTNS session per week for 12 consecutive weeks.12 consecutive weeks
Documented response: The member demonstrates at least 50% improvement in voiding symptoms.≥ 50% improvement
Response may be documented using patient voiding diaries or similar records.

Excluded clinical indications

Not medically necessary when any of the following applies:

Chronic pelvic pain: Treatment is for chronic pelvic pain.
Constipation: Treatment is for constipation.
Fecal incontinence: Treatment is for fecal incontinence.
Neurological voiding dysfunction: Treatment is for voiding dysfunction secondary to a neurological condition.

Noncovered device categories

The following stimulation device categories are not considered medically necessary because of insufficient evidence of therapeutic value:

Excluded stimulation devices

Implantable tibial nerve stimulation, including the eCoin Peripheral Neurostimulator System and Revi, is not considered medically necessary.
Revi was formerly known as the RENOVA iStim system.
Wearable PTNS devices, including the Vivally System and Zida Wearable Neuromodulation System, are not considered medically necessary.
Applicable listed HCPCS codes include A4545, E0737, and E0736.

PTNS is not considered medically necessary for chronic pelvic pain, constipation, fecal incontinence, or voiding dysfunction secondary to a neurological condition because of insufficient evidence of therapeutic value.

Implantable tibial nerve stimulation, including the eCoin Peripheral Neurostimulator System and Revi® (formerly known as the RENOVA™ iStim system), is not considered medically necessary because of insufficient evidence of therapeutic value.

Wearable PTNS devices, including the Vivally® System and Zida Wearable Neuromodulation System, are not considered medically necessary because of insufficient evidence of therapeutic value.

The policy does not consider PTNS medically necessary for chronic pelvic pain, constipation, fecal incontinence, or neurologically secondary voiding dysfunction. It also does not consider implantable tibial nerve stimulation, including eCoin and Revi, or wearable PTNS devices, including Vivally and Zida, medically necessary because of insufficient evidence of therapeutic value.

Covered and Noncovered Coding

Applicable Procedure CodesCPTCovered

64566

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

Applicable ICD-10 Diagnosis CodesICD-10Covered

N32.81	Overactive bladder
N39.41	Urge incontinence
R35.0	Frequency of micturition
R39.15	Urgency of urination

Wearable PTNS Devices Not Medically NecessaryHCPCSNot Covered

A4545	Vivally System or Zida Wearable Neuromodulation System
E0737	Vivally System
E0736	Zida Wearable Neuromodulation System

Initial PTNS Course

FrequencyOne session per week

Session duration30 minutes

Course length12 consecutive weeks

Response for Continuation

Required improvementAt least 50% improvement in voiding symptoms

Response basisDocumented voiding symptoms

Supporting documentation

Authorization and Documentation Requirements

Prior Authorization

Prior Authorization and Specialist Evaluation Required

Prior authorization is required for office-based PTNS for overactive bladder (OAB). Submit clinical evidence showing that the member meets coverage criteria, including evaluation by an appropriate specialist who has determined that the member is a PTNS candidate.

Documentation Required

Submit Clinical Evidence

The treating physician or primary care provider must submit the clinical evidence and supporting documentation to ConnectiCare. Without this information, ConnectiCare cannot properly review the prior authorization request.

Documentation Required

Specialist Evaluation and Candidacy

Document assessment by an appropriate specialist, such as a urologist or urogynecologist, confirming that the member has been evaluated and is a candidate for PTNS for OAB.

Clinical Background

Percutaneous tibial nerve stimulation (PTNS) is an electrical neuromodulation technique used to treat overactive bladder and associated urinary urgency, frequency, and urge incontinence. Treatment uses a percutaneous needle electrode and surface electrodes to deliver adjustable stimulation through the tibial nerve to the sacral nerve plexus. The initial course consists of one 30-minute office treatment per week for 12 consecutive weeks; continued treatment may be provided when the member demonstrates a documented response.

Related Clinical Definitions

Percutaneous Tibial Nerve

TechniqueElectrical neuromodulation for the treatment of voiding dysfunction

Patient populationPatients who have failed behavioral and/or pharmacologic therapies

Clinical useUsed to treat overactive bladder and associated urinary urgency, urinary frequency, and urge incontinence

Increased Daytime Frequency

DefinitionA complaint of voiding too often during the day

Reported byThe individual experiencing the symptom

Symptom period

Policy Summary

PayerConnectiCare

PolicyPosterior Tibial Nerve Stimulation for Voiding Dysfunction

Policy CodePolicy MG.MM.ME.67

Change TypeMaterial update

Effective DateMay 8, 2026

Next Review DateN/A

Key ActionSubmit clinical evidence showing that the member meets the criteria and has been evaluated by an appropriate specialist who determined the member is a candidate for office-based PTNS.

SourceLink

On This Page

Patient voiding diaries may be used

Continued PTNS Frequency

Treatment frequencyTypically 1 treatment every 2–3 weeks

Treatment typeContinued PTNS

Treatment schedulingThe regimen is tailored to each individual member

Continued PTNS Annual Maximum

Annual maximum26 treatments

Measurement periodPer 12 months

Applies toContinued PTNS treatment

Documentation Required

Document Continuation Response

For continued PTNS, document completion of the initial 12-week regimen and the member's response before requesting additional treatment.

Initial regimen: one 30-minute session per week for 12 consecutive weeks.
Response: at least 50% improvement in voiding symptoms, supported by documentation such as patient voiding diaries.
Continuation is typically tailored to the member, often one treatment every 2–3 weeks, with a maximum of 26 treatments per 12 months.

Denial Risk

Excluded Clinical Indications

PTNS is not considered medically necessary for the following indications because of insufficient evidence of therapeutic value.

Chronic pelvic pain
Constipation
Fecal incontinence
Voiding dysfunction secondary to a neurological condition

Denial Risk

Implantable Tibial Stimulation Excluded

Implantable tibial nerve stimulation systems are not considered medically necessary because of insufficient evidence of therapeutic value.

eCoin Peripheral Neurostimulator System
Revi®, formerly known as the RENOVA™ iStim system

Denial Risk

Wearable PTNS Devices Excluded

Wearable PTNS devices are not considered medically necessary because of insufficient evidence of therapeutic value.

Vivally® System — HCPCS A4545, E0737
Zida Wearable Neuromodulation System — HCPCS A4545, E0736

Denial Risk

Continuation Requires Documented Response

Continuation of PTNS may be denied when documentation does not establish completion of the initial 12-week treatment regimen or at least 50% improvement in voiding symptoms.

Document one 30-minute session per week for 12 consecutive weeks.
Document the required symptom response using appropriate clinical evidence, such as patient voiding diaries.

Nocturia

DefinitionA complaint of waking at night one or more times to urinate

Symptom periodNighttime

Urination frequencyOne or more nighttime awakenings to urinate

Urgency

DefinitionA sudden compelling desire to pass urine

DeferralThe desire is difficult to defer

Symptom typeUrinary voiding symptom

Urinary Incontinence

DefinitionAny involuntary leakage of urine

LeakageUrine leakage occurs involuntarily

Symptom typeUrinary symptom