H-wave Electrical Stimulation

Policy ID: E-33-017

Section: Durable Medical Equipment

Effective Date: November 01, 2019

Revised Date: October 02, 2019

Revision Effective Date: November 04, 2024

Last Reviewed: September 17, 2024

Applies To: Commercial and Medicaid Expansion

Description

H-wave stimulation is a form of electrical stimulation that differs from other forms of electrical stimulation, such as transcutaneous electrical nerve stimulation (TENS), in terms of its wave form. H-wave stimulation has been used for the treatment of pain related to a variety of etiologies, such as diabetic neuropathy, muscle sprains, temporomandibular joint dysfunctions or reflex sympathetic dystrophy. H-wave stimulation has also been used to accelerate healing of wounds, such as diabetic ulcers.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

H-wave stimulation is considered experimental/investigational and therefore, non-covered. Review of available literature reveals a lack of controlled clinical trials that prove the effectiveness of the device. As such, the H-wave device used in the home and H-wave stimulation performed in the provider’s office are non-covered.

Procedure Code

E1399

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 9-26-2019 New policy for ND

Internal Medical Policy Committee 9-21-2020 Annual Review

Internal Medical Policy Committee 9-21-2021 Annual Review

Internal Medical Policy Committee 9-28-2022 Annual Review-no change in criteria

Internal Medical Policy Committee 9-12-2023 Annual Review

Internal Medical Policy Committee 9-17-2024 Annual Review-no changes in criteria.

Added Policy Application

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: E-33-017

Section: Durable Medical Equipment

Effective Date: November 01, 2019

Revised Date: October 02, 2019

Revision Effective Date: November 02, 2020

Last Reviewed: September 12, 2023

Archived Date: November 03, 2024

Applies To: Commercial and Medicaid Expansion

Description

Criteria

Procedure Code

E1399

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 9-26-2019 New policy for ND

Internal Medical Policy Committee 9-21-2020 Annual Review

Internal Medical Policy Committee 9-21-2021 Annual Review

Internal Medical Policy Committee 9-28-2022 Annual Review-no change in criteria

Internal Medical Policy Committee 9-12-2023 Annual Review

Links

References (PDF)

Disclaimer

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