Medicare carrier issues negative coverage decision on PTNS

National Government Services (NGS), a regional Medicare carrier, recently issued a future negative coverage decision on posterior tibial nerve stimulation therapy (Urgent PC, Uroplasty, Inc., Minneapolis) that became effective in four states after Jan. 3, 2011.

NGS covers Connecticut, Indiana, Kentucky, and New York.

“This is the first negative coverage decision we have received since the publication of our SUmiT study and the announcement that the American Medical Association would issue a CPT Category I Code to be effective Jan. 1, 2011,” said David Kaysen, Uroplasty president and CEO. “We are disappointed and plan to address this with NGS to work toward a reversal of this decision. Importantly, we do not expect this decision to impact the positive coverage decisions we have already received.”

Uroplasty has previously announced positive coverage decisions by six regional Medicare carriers covering 17 states. The company estimates the total number of Medicare covered lives for which it has received positive coverage decisions is approximately at 12 million. It said NGS covers less than 10% of total Medicare covered lives.

“We plan to meet soon with the medical director of NGS to understand the basis for the decision and work with the carrier to reverse it,” Kaysen said. “We believe this decision is contrary to the strong clinical data that supports PTNS that led to the positive CPT coding decision and the coverage decisions in other jurisdictions.”