LCD for POSTERIOR TIBIAL NERVE STIMULATION (PTNS) for ...
LCD for POSTERIOR TIBIAL NERVE STIMULATION (PTNS) for URINARY CONTROL (DL27267) | |[pic]
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Please note: This is a Future LCD.
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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 |
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|Contractor Name back to top |
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|Palmetto GBA |
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|Contractor Number back to top |
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|00880 |
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|Contractor Type back to top |
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|Carrier |
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|LCD Information |
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|LCD ID Number back to top |
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|DL27267 |
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|LCD Title back to top |
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|POSTERIOR TIBIAL NERVE STIMULATION (PTNS) for URINARY CONTROL |
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|Contractor's Determination Number back to top |
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|PTNS.092008 |
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|AMA CPT / ADA CDT Copyright Statement back to top |
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|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. |
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|CMS National Coverage Policy back to top |
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|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. |
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|Internet Only Manual (IOM) Publication 100-03 National Coverage Determination Manual Chapter 1, Section 230.16 |
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|Primary Geographic Jurisdiction back to top |
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|South Carolina |
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|Oversight Region back to top |
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|Region IV |
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|Projected Determination Effective Date back to top |
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|For services performed on or after 09/01/2008 |
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|Original Determination Ending Date back to top |
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|Revision Effective Date back to top |
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|Revision Ending Date back to top |
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|Indications and Limitations of Coverage and/or Medical Necessity back to top |
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|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. |
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|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. |
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|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. |
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|Lacking sufficient scientific data to support the use of PTNS, Medicare considers PTNS investigational and therefore, is |
|not reasonable and necessary. |
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|Coverage Topic back to top |
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|Doctor Office Visits |
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|Coding Information |
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|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. |
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|999x |
|Not Applicable |
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|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. |
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|99999 |
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|CPT/HCPCS Codes back to top |
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|CPT Code |
|64550 |
|APPLICATION OF SURFACE (TRANSCUTANEOUS) NEUROSTIMULATOR |
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|ICD-9 Codes that Support Medical Necessity back to top |
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|N/A Not Applicable |
|XX000 |
|Not Applicable |
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|Diagnoses that Support Medical Necessity back to top |
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|ICD-9 Codes that DO NOT Support Medical Necessity back to top |
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|307.6 |
|ENURESIS |
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|307.89 |
|OTHER, PAIN DISORDER RELATED TO PSYCHOLOGICAL FACTORS |
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|596.51 |
|HYPERTONICITY OF BLADDER |
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|599.82 |
|INTRINSIC (URETHRAL) SPHINCTER DEFICIENCY [ISD] |
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|618.83 |
|PELVIC MUSCLE WASTING |
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|625.6 |
|STRESS INCONTINENCE FEMALE |
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|625.9 |
|UNSPECIFIED SYMPTOM ASSOCIATED WITH FEMALE GENITAL ORGANS |
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|787.6 |
|INCONTINENCE OF FECES |
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|788.20 - 788.21 |
|RETENTION OF URINE UNSPECIFIED - INCOMPLETE BLADDER EMPTYING |
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|788.30 - 788.39 |
|URINARY INCONTINENCE UNSPECIFIED - OTHER URINARY INCONTINENCE |
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|788.41 |
|URINARY FREQUENCY |
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|788.63 |
|URGENCY OF URINATION |
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|788.64 |
|URINARY HESITANCY |
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|788.9 |
|OTHER SYMPTOMS INVOLVING URINARY SYSTEM |
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|ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation back to top |
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|Diagnoses that DO NOT Support Medical Necessity back to top |
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|General Information |
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|Documentation Requirements back to top |
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|N/A |
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|Appendices back to top |
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|Utilization Guidelines back to top |
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|N/A |
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|Sources of Information and Basis for Decision back to top |
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|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. |
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|Amarenco G et al. Urodynamic Effect of Acute Transcutaneous Posterior Tibial Nerve Stimulation in Overactive Bladder. J |
|Urol. 2003;169(6):2210-5. |
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|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. |
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|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. |
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|Congregado R B et al. Peripheral Afferent Nerve Stimulation for Treatment of Lower Urinary Tract Irritative Symptoms. Eur |
|Urol. 2004;45(1):65-9. |
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|Cooperberg M R, Stoller M L. Percutaneous Neuromodulation. Urol Clin N Am. 2005;32:71-8. |
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|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. |
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|Govier F E et al. Percutaneous Tibial Nerve Stimulation in Lower Urinary Tract Disorders. J Urol. 2001;165:884-886. |
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|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. |
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|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. |
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|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. |
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|Vandonick V et al. Posterior Tibial Nerve Stimulation in the Treatment of Urge Incontinence. J Urol. 2003;169(6):2429-30. |
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|Vandonick V et al. Percutaneous Tibial Nerve Stimulation in the Treatment of Overactive Bladder: Urodynamic Data. J Urol. |
|2003;22(3):1051. |
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|Vandonick V et al. Posterior Tibial Nerve Stimulation in the Treatment of Idiopathic Nonobstructive Voiding Dysfunction. J |
|Urol. 2003;61(3):567-72. |
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|Advisory Committee Meeting Notes back to top |
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|South Carolina Meeting: 4/02/08 |
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|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. |
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|Start Date of Comment Period back to top |
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|04/02/2008 |
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|End Date of Comment Period back to top |
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|05/17/2008 |
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|Start Date of Notice Period back to top |
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|Revision History Number back to top |
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|Revision History Explanation back to top |
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|Reason for Change back to top |
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|Last Reviewed On Date back to top |
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|03/19/2008 |
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|Related Documents back to top |
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|This LCD has no Related Documents. |
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|LCD Attachments back to top |
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|There are no attachments for this LCD |
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|Draft Contact back to top |
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|Elaine Jeter, MD - B.policy@ |
|PO Box 100190 |
|Columbia, SC 29202 |
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