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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that Posterior Tibial Nerve Stimulation (PTNS) is a minimally invasive neuromodulation system 
designed to deliver retrograde electrical stimulation to the sacral nerve plexus through percutaneous electrical 
stimulation of the posterior tibial nerve. Noridian has determined that PTNS will be covered for treatment of 
urinary urgency, urinary frequency, and urge incontinence. This article does not address the following 
NCD: CMS Internet Only Manual (IOM) Medicare National Coverage Determination (NCD) Manual, 
Publication 100-03, Section 230.16 Bladder Stimulators (Pacemakers)  
 
PTNS Procedure Description 
The posterior tibial nerve contains mixed sensory motor nerve fibers that originate from L4 through S3, which 
modulate the innervation to the bladder, urinary sphincter and pelvic floor. The specific mechanism of action of 
neuromodulation is unclear, although theories include improved blood flow and change in neurochemical 
balance along the neurons. Neuromodulation may have a direct effect on the detrusor or a central effect on the 
micturition centers of the brain. 
 
Using a battery-powered, handheld stimulator and a 34-gauge needle electrode, one can access and stimulate 
the tibial nerve. Patients receive one 30-minute weekly treatment in the office for 12 weeks. Patients treated 
with PTNS may begin to see changes in their voiding patterns after four to six treatments, with nocturia and 
urge incontinence decreases usually reported first. Patients who respond to the treatment require additional 
therapy at individually-defined treatment intervals for sustained relief of symptoms. 
 
Coverage Guidelines 
Consistent with Noridian, manufacturer instructions, and existing literature descriptions of appropriate clinical 
usage, Noridian expects this treatment to be (generally) delivered in an office setting (Place of Service 11) and 
that the standard treatment regimen will consist of one 30-minute sessions given once weekly for 12 weeks. 
 
Coverage for initial therapy must document failed standard anticholinergic drug therapy or that the patient demonstrates intolerance to the anticholinergic drug therapy despite best attempts at management of the most 
common side effects of such therapy, such as dry mouth and constipation. 
 
Coverage for maintenance therapy on an every-three-weeks basis can be extended for a longer time to patients 
who demonstrate significant improvement in overactive bladder (OAB) symptoms during and at the end of the 
standard 12-week course of therapy. Documentation must support the initial improvement and the need for the 
additional treatments. 
 
Bill no more than three Evaluation and Management (E&M) services during any initial course of PTNS 
treatment: 
1. On the initial visit; 
2. At the 5th or 6th visit to assess progress; and 
3. At the end of the initial 12-week course of therapy. 
 
The patients medical record must contain adequate documentation identifying the CPT

 and ICD-10-CM 
coding, and the need for and level of these visits. Noridian reminds the provider community that this coverage 
decision may be modified or terminated depending upon future literature or clinical experience and usage. 
 
You can find this rule at the Medicare Local Coverage Article (LCA) A55104: Billing and Coding: Posterior 
Tibial Nerve Stimulation Coverage. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.