Medicare - First Coast Service Options, Inc.
FirstCoast Service Options, Inc., the Medicare carrier for Florida, Puerto Rico, and the U.S. Virgin Islands, has issued a coverage policy for PTNS effective April 23, 2013. FCSO considers PTNS medically necessary for patients that meet certain criteria.
According to FCSO, PTNS may be considered medically necessary and covered to treat patients with overactive bladder and associated symptoms when ALL of the following criteria have been met:
- The patient has experienced OAB with associated symptoms of urinary urgency, urinary frequency, and urge incontinence for at least 12 months and the condition has resulted in significant disability;
- The patient has tried at least two different anti-cholinergic drugs, or a combination of an anti-cholinergic and a tricyclic drug for a period of four to six weeks without improvement, or the documentation shows the patient is unable to tolerate these type drugs; and
- The patient has tried behavioral treatments (e.g., pelvic floor exercise, biofeedback, timed voids, or fluid management - not an all inclusive list) without improvement in the symptoms.
PTNS standard treatment regimen (30-minute sessions given weekly for 12 weeks) will be covered. If the beneficiary fails to improve after 6 treatments, continued treatment is not considered medically necessary. Treatments beyond the initial 12 sessions will be allowed at a frequency of one every one to two months for the remainder of one year. Another trial of the PTNS 12-week standard treatment regimen will be allowed after 24 months for patients who have had successful treatment with PTNS and have returning symptoms of OAB.
Please visit the Medicare Coverage Database for the complete details of the policy and the most up to date information.