HCPCS E0736 is officially defined as "Transcutaneous tibial nerve stimulator." HCPCS E0736 is referenced in 10 tracked payer policy changes from Sentara Health Plans, Medical Mutual of Ohio, and 5 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for HCPCS E0736 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Starting January 1, 2027, Sentara Health Plans will require prior authorization for a long list of codes on Virginia commercial plans, including self-funded (ASO) plans, and for code 88380 on commercial, Medicaid and Medicare products, plus code 22860 on Medicare products. Sentara will also stop covering a separate list of codes on Virginia commercial and self-funded plans.
Medical Mutual is implementing major prior authorization changes effective June 2026, including new PA requirements for dozens of CPT codes (imaging, cardiovascular, spine procedures) and removing PA requirements for others. A new reimbursement policy for IMRT radiation therapy is also effective June 1, 2026.
Section 110.8 of the Medicare Benefit Policy Manual is updated to reflect DMEPOS benefit category determinations for the 2025 biannual 1 and 2 Level II HCPCS coding cycles. Each listed code is assigned a benefit category, such as DME, Prosthetic Device, Back Brace, Leg Brace, Prosthetic (Artificial Leg or Arm), Lymphedema Compression Treatment Item, or No Medicare DMEPOS benefit category. This update makes no change in policy.
Effective April 1, 2026, Carelon Medical Benefits Management will require prior authorization for 30 specific HCPCS and CPT codes related to tibial nerve stimulators, autografts, and tissue/membrane products for Anthem Blue Cross and Blue Shield commercial plans in Virginia. Billing teams must update systems to flag these codes for prior auth requests before the effective date.
Effective April 1, 2026, Carelon Medical Benefits Management will require prior authorization for 30 specific HCPCS and CPT codes related to tibial nerve stimulators, autografts, and advanced wound care matrices. Billing teams must implement prior authorization workflows for these codes in their system and ensure providers submit requests through Carelon's ProviderPortal or Availity before delivering these supplies and services.
Effective April 1, 2026, Carelon Medical Benefits Management (on behalf of Anthem Blue Cross and Blue Shield in Ohio) is adding 30 specific CPT and HCPCS codes to its prior authorization requirements. These codes primarily cover external tibial nerve stimulation devices and biologic/synthetic wound care matrices and grafts. Billing teams must update systems to require prior authorization for all claims using these codes for Ohio commercial members.
Effective April 1, 2026, Carelon Medical Benefits Management will require prior authorization for 30 specific CPT and HCPCS codes related to tibial nerve stimulators, autografts, and advanced wound care/tissue matrices for Georgia commercial plans. Billing teams must implement prior authorization requirements in their systems and submission workflows for these codes.
Aetna Clinical Policy Bulletin 0223 on urinary incontinence, reviewed 2026-07-16, considers multi-channel urodynamic studies medically necessary when a member has both symptoms and physical findings of urinary incontinence or voiding dysfunction and the provider is considering invasive, potentially morbid or irreversible treatment after conservative management has failed. It considers medically necessary the artificial urinary sphincter, FDA-cleared peri-urethral bulking agents, permanent sacral nerve stimulators after temporary trial stimulation, percutaneous tibial nerve stimulation, weighted vaginal cones, pessaries, tension-free and transobturator tape procedures, colposuspension and sub-urethral sling procedures when the stated criteria are met. Bilateral permanent sacral nerve stimulator implantation, the Genityte and FemiLift laser procedures, stem cell therapy and many other listed interventions are considered experimental, investigational or unproven.
A 09/15/2025 policy history entry retitled the policy from Percutaneous and Subcutaneous Tibial Nerve Stimulation to Tibial Nerve Stimulation and added a statement that transcutaneous tibial nerve stimulation (e.g., Vivally System) is investigational for individuals with urge urinary incontinence and urinary urgency. HCPCS codes A4545, E0736 and E0737 were added to the investigational codes table. Percutaneous tibial nerve stimulation is medically necessary for an initial 12-week course for non-neurogenic urinary dysfunction, including overactive bladder, after failed behavioral therapy and failed pharmacologic therapy, and for monthly maintenance after an initial course that resulted in improved urinary dysfunction meeting treatment goals.
Effective January 3, 2025, Premera HMO medical necessity criteria for Dupixent (dupilumab) in moderate to severe asthma were updated, requiring two or more asthma exacerbations in the previous 12 months requiring oral corticosteroids, or one or more exacerbations requiring hospitalization, an emergency department visit, or an urgent care visit, or forced expiratory volume in 1 second of less than 80% predicted, with a blood eosinophil count greater than 300 cells/mcL. The same effective date added Humira (adalimumab) criteria for psoriatic arthritis, Crohn's disease, ulcerative colitis, uveitis, sarcoidosis and pyoderma gangrenosum, moved Inflectra (infliximab-dyyb) to a first-line TNF-alpha antagonist option for several indications, and removed Hyrimoz (adalimumab-adaz) from first-line options. A new Shoulder Arthroplasty policy (7.01.590) with medical necessity criteria for total, reverse, hemi, and revision shoulder arthroplasty is also listed under the January 3, 2025 effective date, and Restasis (cyclosporine ophthalmic emulsion) was added for dry eye disease in individuals aged 18 years and older effective October 1, 2024.
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