Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for percutaneous tibial nerve stimulation once a month for treatment of the enrollees overactive bladder. Findings:  2/3 of the physician reviewers found that there is evidence in the peer-reviewed literature from randomized trials and prospective observational trials supporting the clinical utility and impact on patient management of percutaneous tibial nerve stimulation in patients with urinary urgency and frequency as in this case. However, most trials have a small number of patients with short-term follow-up.  The current guidelines recommend that clinicians should offer behavioral therapies (e.g., bladder training, bladder control strategies, pelvic floor muscle training, and fluid management) as first-line therapy to all patients with overactive bladder. Behavioral therapies may be combined with pharmacologic management. Clinicians should offer oral antimuscarinics or oral beta-3 adrenoceptor agonists as second-line therapy. If a patient experiences inadequate symptom control and/or unacceptable adverse drug events with one anti-muscarinic medication, then a dose modification or a different anti-muscarinic medication or a beta-3 adrenoceptor agonist may be tried. Patients who are refractory to behavioral and pharmacologic therapy should be evaluated by an appropriate specialist if they desire additional therapy. The guidelines rate percutaneous tibial nerve stimulation as third-line therapy. The role of percutaneous tibial nerve stimulation in men with overactive bladder and nocturnal enuresis is largely unknown. Most studies evaluating efficacy of percutaneous tibial nerve stimulation are done on women with refractory overactive bladder. Current scientific evidence does not support routine use of percutaneous tibial nerve stimulation in men with lower urinary tract symptoms refractory to medical therapy.  Therefore, percutaneous tibial nerve stimulation once a month was not and is not likely to be more effective than other treatment options. Final Result: 2/3 of the reviewers determined that the services at issue were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.