Percutaneous tibial nerve stimulation for an initial 12-week course is considered medically necessary for individuals with non-neurogenic urinary dysfunction including overactive bladder who have both:
failed behavioral therapy following an appropriate duration of 8 to 12 weeks without meeting treatment goals; and
failed pharmacologic therapy following 4 to 8 weeks of treatment without meeting treatment goals.
Maintenance therapy using monthly percutaneous tibial nerve stimulation is considered medically necessary for individuals following a 12-week initial course of percutaneous tibial nerve stimulation that resulted in improved urinary dysfunction meeting treatment goals.
Percutaneous tibial nerve stimulation is considered investigational for all other indications, including but not limited to the following:
Neurogenic bladder dysfunction