BlueCross BlueShield of Tennessee Medical Policy Manual

Percutaneous Tibial Nerve Stimulation (PTNS)

DESCRIPTION

Percutaneous tibial nerve stimulation (PTNS) also known as posterior tibial nerve stimulation; is a technique of electrical neuromodulation used primarily for treating voiding dysfunction.  Altering the function of the posterior tibial nerve with PTNS is believed to improve voiding function and control.  Although the posterior tibial nerve is located near the ankle, it is derived from the lumbar-sacral nerves (L4-S3), which controls the bladder detrusor and perineal floor.  Voiding dysfunction includes urinary frequency, urgency, incontinence and nonobstructive retention.  Common causes of voiding dysfunction are pelvic floor dysfunction (e.g., pregnancy, childbirth, or surgery), inflammation, medication, obesity, psychogenic factors and disease (e.g., multiple sclerosis, spinal cord injury, diabetes with peripheral nerve involvement).

The procedure for PTNS consists of the insertion of a needle above the medial malleolus into the posterior tibial nerve followed by the application of low-voltage electrical stimulation that produces sensory and motor responses.  The recommended treatment is an initial series of 12 weekly office-based treatments followed by an individualized maintenance treatment schedule. A similar treatment schedule has been proposed to treat fecal incontinence; however this application of the technology does not have FDA approval.

POLICY

Policies with similar titles: Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT)

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

Systematic reviews of the evidence have found short-term improvements with PTNS related to urinary dysfunction but have not identified long-term comparative studies.  There is insufficient evidence that PTNS is effective for other conditions such as fecal incontinence.

SOURCES

Agency for Healthcare Research and Quality. (2012). Comparative Effectiveness Review Number 36. Nonsurgical treatments for urinary incontinence in adult women: diagnosis and comparative effectiveness. Retrieved October 16, 2015 from http://effectivehealthcare.ahrq.gov.

American Urological Association Education and Research, Inc. & Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction. (May, 2014). Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. Retrieved June 13, 2017 from http://www.auanet.org/guidelines.

BlueCross BlueShield Association. Medical Policy Reference Manual. (1:2016). Percutaneous tibial nerve stimulation (7.01.106). Retrieved June 13, 2017 from BlueWeb. (31 articles and/or guidelines reviewed)

Cahaba Government Benefit Administrators, LLC. (2015, October). Posterior tibial nerve stimulation (PTNS) for urinary control (L34296). Retrieved October 15, 2015 from https://www.cms.gov.

California Technology Assessment Forum. (2012, June). Percutaneous tibial nerve stimulation for the treatment of overactive bladder. Retrieved October 16, 2015 from https://icerreview.org. 

Edenfield, A.L., Amundsen, C.L., Wu, J.M., Levin, P.J., & Siddiqui, N.Y. (2015). Posterior tibial nerve stimulation for the treatment of fecal incontinence: a systematic evidence review. Obstetrical & Gynecological Survey, 70 (5), 329-341. Abstract retrieved October 16, 2015 from PubMed database.

Gaziev, G., Topazio, L., Iacovelli, V., Asimakopoulos, A. Di Santo, A., De Nunzio, A., et. al. (2013) Percutaneous tibial nerve stimulation (PTNS) efficacy in the treatment of lower urinary tract dysfunctions: a systematic review. BioMed Central: Urology 13:61. (Level 2 evidence)

Horrocks, E.J., Bremner, S.A., Stevens, N., Norton, C., Gilbert, D., O’Connell, P.R., et al. (2015). Double-blind randomized controlled trial of percutaneous tibial nerve stimulation versus sham electrical stimulation in the treatment of faecal incontinence: CONtrol of faecal incontinence using distal neuromodulation (the CONFIDeNT trial). Health Technology Assessment, 19 (77), 1-164, Abstract retrieved October 16, 2015 from PubMed database.

National Institute for Health and Clinical Excellence. (2007). Clinical guideline: Faecal incontinence in adults: management. Retrieved October 3, 2016 from www.nice.org.uk.

National Institute for Health and Clinical Excellence. (2011). Clinical guideline: Urinary incontinence in women: management. Retrieved October 3, 2016 from www.nice.org.uk.

Preyer, O., Umek, W., Lami, T., Bjelic-Radisic, V., Gabriel, B.,Mittlboeck, M., & Hanzal, E. (2015). Percutaneous tibial nerve stimulation versus tolterodine for overactive bladder in women: a randomized controlled trial. European Journal of Obstetrics, Gynecology and Reproductive Biology, 191, 56 – 56. Abstract retrieved October 16, 2015 from PubMed database.

Schneider, M., Gross, T., Bachmann, L., Blok, B., Castro-Diaz, D., Del Popolo, G, et. al. (2015, November) Tibial nerve stimulation for treating neurogenic lower urinary tract dysfunction: a systematic review. European Urology, 68(5):859-67. Abstract retrieved October 3, 2016 from PubMed database.

Technology Evaluation Center. (2014, January). Percutaneous tibial nerve stimulation for the treatment of voiding dysfunction. Vol. 28, No. 10). Retrieved October 15, 2015 from http://www.bcbs.com (44 articles and/or guidelines reviewed)

U.S. Food & Drug Administration. (2007, August). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K071822 (Urgent® ©). Retrieved December 17, 2010 from: http://www.accessdata.fda.gov. 

Wibisono, E., and Rahardjo, H. (2015, July) Effectiveness of Short Term Percutaneous Tibial Nerve Stimulation for Non-neurogenic Overactive Bladder Syndrome in Adults: A Meta-analysis. The Indonesian Journal of Internal Medicine. Vol. 477, No. 3, p. 188-200. (Level 1 evidence)

Winifred S. Hayes, Inc. Medical Technology Directory. (2008, September; last update search November 2016). Percutaneous tibial nerve stimulation for the treatment of lower urinary tract dysfunction. Retrieved June 13, 2017 from www.Hayesinc.com (95 articles and/or guidelines reviewed)

ORIGINAL EFFECTIVE DATE:  9/9/2007

MOST RECENT REVIEW DATE:  8/10/2017

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Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

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