Criteria
Coverage is subject to the specific terms of the member's benefit plan.
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; 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.
Electrical stimulation may be considered medically necessary for the management of the following types of chronic ulcers when it is used as adjunctive therapy after there are no measurable signs of healing for at least 30 days of treatment with conventional wound treatments.
- Arterial ulcers; or
- Diabetic ulcers; or
- Pressure ulcers (Stage III or Stage IV); or
- Venous stasis ulcers
Continued treatment considered not medically necessary if measurable signs of healing have not been demonstrated within any 30-day period of treatment.
• Measurable signs of improved healing include a decrease in wound size either in surface area or volume, decrease in amount of exudates, and decrease in amount of necrotic tissue.
• If electrical stimulation is being used, wounds must be evaluated at least monthly by the treating physician.
All other uses of electrical stimulation for the treatment of chronic ulcers not meeting the criteria as indicated in this policy are considered not medically necessary.
Electrical stimulation for wound healing is not covered in the home setting.
Procedure Codes
