Interferential Stimulator

Policy ID: E-45-018

Section: Durable Medical Equipment

Effective Date: July 01, 2018

Revised Date: May 14, 2018

Revision Effective Date: November 04, 2024

Last Reviewed: September 17, 2024

Applies To: Commercial and Medicaid Expansion

Description

Interferential stimulation is a type of electrical nerve stimulation that uses paired electrodes of two independent circuits carrying medium-frequency alternating currents. The electrodes are aligned on the skin so that the current flowing between each pair intersects at the underlying target. This maximizes the current permeating the tissues while minimizing unwanted stimulation of cutaneous nerves.

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 processing, regardless of service date; and/or

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

Coverage is subject to the specific terms of the member's benefit plan.

Interferential stimulation is experimental/investigational.

Review of available literature reveals a lack of controlled clinical trials that prove the effectiveness of the procedure.

Procedure Codes

A4556

A4557

S8130

S8131

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 9-21-2020 Annual Review - no changes

Internal Medical Policy Committee 9-21-2021 Annual Review - no changes

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

Internal Medical Policy Committee 9-12-2023 Annual Review - no changes in criteria

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-45-018

Section: Durable Medical Equipment

Effective Date: July 01, 2018

Revised Date: May 14, 2018

Last Reviewed: September 12, 2023

Archived Date: November 03, 2024

Applies To: Commercial and Medicaid Expansion

Description

Criteria

Coverage is subject to the specific terms of the member's benefit plan. Interferential stimulation is experimental/investigational.

Review of available literature reveals a lack of controlled clinical trials that prove the effectiveness of the procedure.

Procedure Codes

A4556

A4557

S8130

S8131

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 9-21-2020 Annual Review - no changes

Internal Medical Policy Committee 9-21-2021 Annual Review - no changes

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

Internal Medical Policy Committee 9-12-2023 Annual Review - no changes in criteria

Links

References (PDF)

Disclaimer

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