LCD for POSTERIOR TIBIAL NERVE STIMULATION (PTNS) for ...



LCD for POSTERIOR TIBIAL NERVE STIMULATION (PTNS) for URINARY CONTROL (DL27267) | |[pic]

Top of Form

[pic]

Bottom of Form

[pic]

Please note: This is a Future LCD.

[pic]

Please note: This is a Draft policy.

Draft LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Draft LCDs are not necessarily a reflection of the current policies or practices of the contractor.

|Contractor Information |

|[pic][pic] |

| |

|[pic][pic][pic] |

| |

|Contractor Name back to top |

| |

|Palmetto GBA  |

| |

|Contractor Number back to top |

| |

|00880  |

| |

|Contractor Type back to top |

| |

|Carrier  |

| |

|LCD Information |

|[pic][pic] |

| |

|[pic][pic][pic] |

| |

|LCD ID Number back to top |

| |

|DL27267  |

| |

|  |

| |

|LCD Title back to top |

| |

|POSTERIOR TIBIAL NERVE STIMULATION (PTNS) for URINARY CONTROL  |

| |

|  |

| |

|Contractor's Determination Number back to top |

| |

|PTNS.092008  |

| |

|  |

| |

|AMA CPT / ADA CDT Copyright Statement back to top |

| |

|CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of |

|publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including|

|procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental |

|Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.   |

| |

|  |

| |

|CMS National Coverage Policy back to top |

| |

|Title XVIII of the Social Security Act, Section 1862(a)(1)(A) allows coverage and payment for items and services that are |

|reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a |

|malformed body member. |

| |

|Internet Only Manual (IOM) Publication 100-03 National Coverage Determination Manual Chapter 1, Section 230.16 |

|  |

| |

|  |

| |

|Primary Geographic Jurisdiction back to top |

| |

|South Carolina |

|  |

| |

|  |

| |

|Oversight Region back to top |

| |

|Region IV |

|  |

| |

|  |

| |

|  |

| |

|Projected Determination Effective Date back to top |

| |

|For services performed on or after 09/01/2008   |

| |

|  |

| |

|Original Determination Ending Date back to top |

| |

|  |

| |

|  |

| |

|Revision Effective Date back to top |

| |

|  |

| |

|  |

| |

|Revision Ending Date back to top |

| |

|  |

| |

|  |

| |

|Indications and Limitations of Coverage and/or Medical Necessity back to top |

| |

|Posterior Tibial Nerve Stimulation (PTNS), a minimally invasive procedure, consists of insertion of an acupuncture needle |

|above the medial malleolus into a superficial branch of the posterior tibial nerve. An adjustable low voltage electrical |

|impulse (10mA, 1-10 Hz frequency) travels via the posterior tibial nerve to the sacral nerve plexus and is thought to alter|

|pelvic floor function by neuromodulation. Treatment regimens consist of 30-minute weekly sessions for 12 weeks. PTNS has |

|been used for diverse pelvic floor dysfunction including but not limited to urinary frequency, urgency, incontinence, |

|non-obstructive retention, detrusor hypocontractility, bowel dysfunction, pelvic pain and overactive bladder with varying |

|and conflicting degrees of success. |

| |

|Section 1862(a)(1)(A) of the Social Security Act is the basis for denying payment for types of care, specific items, |

|services, or procedures, not excluded by any other statutory clause, meeting all technical requirements for coverage, but |

|are determined to be any of the following: |

|Not generally accepted in the medical community as safe and effective in the setting and for the condition for which it is |

|used |

|Not proven to be safe and effective based on peer review or scientific literature |

|Experimental |

|Not medically necessary in the particular case |

|Furnished at a level, duration or frequency that is not medically appropriate |

|Not furnished in accordance with accepted standards of medical practice, or |

|Not furnished in a setting (such as inpatient care at a hospital or SNF, outpatient care through a hospital or physician's |

|office or home care) appropriate to the patient's medical needs and condition. |

| |

|Items and services must be established as safe and effective to be considered medically necessary. That is, the items and |

|services must be: |

|Consistent with the symptoms or diagnosis of the illness or injury under treatment; |

|Necessary for, and consistent with, generally accepted professional medical standards of care (e.g., not experimental or |

|investigational); |

|Not furnished primarily for the convenience of the patient, the attending physician or other physician or supplier; |

|Furnished at the most appropriate level that can be provided safely and effectively to the patient. |

| |

|Lacking sufficient scientific data to support the use of PTNS, Medicare considers PTNS investigational and therefore, is |

|not reasonable and necessary. |

|  |

| |

|  |

| |

|Coverage Topic back to top |

| |

|Doctor Office Visits |

|  |

| |

|Coding Information |

|[pic][pic] |

| |

|[pic][pic][pic] |

| |

|Bill Type Codes: back to top |

|Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. |

|Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill |

|Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all |

|claims. |

| |

|999x |

|Not Applicable |

| |

|  |

| |

|  |

| |

|Revenue Codes: back to top |

|Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service.|

|In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue |

|Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is |

|not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes. |

| |

|99999 |

| |

| |

|  |

| |

|  |

| |

|CPT/HCPCS Codes back to top |

| |

|CPT Code |

|64550 |

|APPLICATION OF SURFACE (TRANSCUTANEOUS) NEUROSTIMULATOR |

| |

| |

| |

|  |

| |

|  |

| |

|ICD-9 Codes that Support Medical Necessity back to top |

| |

|N/A Not Applicable |

|XX000 |

|Not Applicable |

| |

| |

| |

|  |

| |

|  |

| |

|Diagnoses that Support Medical Necessity back to top |

| |

|  |

| |

|  |

| |

|ICD-9 Codes that DO NOT Support Medical Necessity back to top |

| |

| |

|307.6 |

|ENURESIS |

| |

|307.89 |

|OTHER, PAIN DISORDER RELATED TO PSYCHOLOGICAL FACTORS |

| |

|596.51 |

|HYPERTONICITY OF BLADDER |

| |

|599.82 |

|INTRINSIC (URETHRAL) SPHINCTER DEFICIENCY [ISD] |

| |

|618.83 |

|PELVIC MUSCLE WASTING |

| |

|625.6 |

|STRESS INCONTINENCE FEMALE |

| |

|625.9 |

|UNSPECIFIED SYMPTOM ASSOCIATED WITH FEMALE GENITAL ORGANS |

| |

|787.6 |

|INCONTINENCE OF FECES |

| |

|788.20 - 788.21 |

|RETENTION OF URINE UNSPECIFIED - INCOMPLETE BLADDER EMPTYING |

| |

|788.30 - 788.39 |

|URINARY INCONTINENCE UNSPECIFIED - OTHER URINARY INCONTINENCE |

| |

|788.41 |

|URINARY FREQUENCY |

| |

|788.63 |

|URGENCY OF URINATION |

| |

|788.64 |

|URINARY HESITANCY |

| |

|788.9 |

|OTHER SYMPTOMS INVOLVING URINARY SYSTEM |

| |

|  |

| |

|  |

| |

|ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation back to top |

| |

|  |

| |

|  |

| |

|Diagnoses that DO NOT Support Medical Necessity back to top |

| |

|  |

| |

|General Information |

|[pic][pic] |

| |

|[pic][pic][pic] |

| |

|Documentation Requirements back to top |

| |

|N/A  |

| |

|  |

| |

|Appendices back to top |

| |

|  |

| |

|  |

| |

|Utilization Guidelines back to top |

| |

|N/A  |

| |

|  |

| |

|Sources of Information and Basis for Decision back to top |

| |

|The development and coverage guidelines in this policy were based on a review of pertinent medical literature, policies |

|from other Medicare contractors, and discussions with appropriate specialists. |

| |

|Amarenco G et al. Urodynamic Effect of Acute Transcutaneous Posterior Tibial Nerve Stimulation in Overactive Bladder. J |

|Urol. 2003;169(6):2210-5. |

| |

|Bosch R et al. Sacral Nerve Neuromodulation in the Treatment of Patients with Refractory Motor Urge Incontinence: Long Term|

|Results of a Prospective Longitudinal Study. J Urol. 2000;63:219-22. |

| |

|Bower W F et al. A Pilot Study of the Home Application of Transcutaneous Neuromodulation in Children with Urgency or Urge |

|Incontinence. J Urol. 2001;166(6):2420-2. |

| |

|Congregado R B et al. Peripheral Afferent Nerve Stimulation for Treatment of Lower Urinary Tract Irritative Symptoms. Eur |

|Urol. 2004;45(1):65-9. |

| |

|Cooperberg M R, Stoller M L. Percutaneous Neuromodulation. Urol Clin N Am. 2005;32:71-8. |

| |

|De Gennaro M et al. Percutaneous Tibial Nerve Neuromodulation is Well Tolerated in Children and Effective for Treating |

|Refractory Vesical Dysfunction. J Urol. 204;171(5):1911-3. |

| |

|Govier F E et al. Percutaneous Tibial Nerve Stimulation in Lower Urinary Tract Disorders. J Urol. 2001;165:884-886. |

| |

|Hoebeke P et al. Percutaneous Electrical Nerve Stimulation in Children with Therapy Resistant Nonneuropathic bladder |

|sphincter dysfunction: A Pilot Study. J Urol. 2002;168(6):26005-7. |

| |

|Klinger H C et al. Use of Peripheral Neuromodulation of the S3 region for Treatment of Detrusor Oceractivity: A |

|Urodynamic-Based Study. Urol. 2000;56(5):766-71. |

| |

|Spinelli M et al. New Sacral Neuromodulation Lead for Percutaneous implantation using Local Anesthesia: Description and |

|First Experience. J Urol. 2003; 170(5):1905-7. |

| |

|Vandonick V et al. Posterior Tibial Nerve Stimulation in the Treatment of Urge Incontinence. J Urol. 2003;169(6):2429-30. |

| |

|Vandonick V et al. Percutaneous Tibial Nerve Stimulation in the Treatment of Overactive Bladder: Urodynamic Data. J Urol. |

|2003;22(3):1051. |

| |

|Vandonick V et al. Posterior Tibial Nerve Stimulation in the Treatment of Idiopathic Nonobstructive Voiding Dysfunction. J |

|Urol. 2003;61(3):567-72. |

|  |

| |

|  |

| |

|Advisory Committee Meeting Notes back to top |

| |

|South Carolina Meeting: 4/02/08 |

| |

|This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision|

|rests with the contractor, this policy was developed in cooperation with advisory groups. |

|  |

| |

|  |

| |

|Start Date of Comment Period back to top |

| |

|04/02/2008  |

| |

|  |

| |

|End Date of Comment Period back to top |

| |

|05/17/2008  |

| |

|  |

| |

|Start Date of Notice Period back to top |

| |

|  |

| |

|  |

| |

|Revision History Number back to top |

| |

|  |

| |

|  |

| |

|Revision History Explanation back to top |

| |

|  |

| |

|  |

| |

|Reason for Change back to top |

| |

|  |

| |

|Last Reviewed On Date back to top |

| |

|03/19/2008  |

| |

|  |

| |

|Related Documents back to top |

| |

|This LCD has no Related Documents. |

| |

|  |

| |

|LCD Attachments back to top |

| |

|There are no attachments for this LCD |

| |

| |

| |

|  |

| |

|Draft Contact back to top |

| |

|Elaine Jeter, MD - B.policy@ |

|PO Box 100190 |

|Columbia, SC 29202 |

| |

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download