Electrical Nerve Stimulation

Policy ID: Z-7-058

Section: Miscellaneous

Effective Date: July 01, 2018

Revised Date: September 29, 2024

Revision Effective Date: October 01, 2024

Last Reviewed: September 17, 2024

Applies To: Commercial and Medicaid Expansion

Description

Electrical nerve stimulation is the use of electric current produced by a device to stimulate the nerves for therapeutic purposes.

Policy Application

For Date of Processing (DOP): All claims submitted for this policy 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

For Date of Service (DOS): All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

*See below to determine whether the policy rules apply to initial and adjustment claims based on date of processing (DOP) or Date of Service (DOS).

Criteria

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

Electrical Nerve Stimulation, (Transcutaneous Electrical Nerve Stimulation (TENS) and Percutaneous Electrical Nerve Stimulation) (PENS)

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.

Electrical nerve stimulation, (Transcutaneous electrical nerve stimulation (TENS) and Percutaneous electrical nerve stimulation) (PENS) may be considered medically necessary when used for the treatment of acute or chronic pain and as a means of assessing the need for continued treatment with an implanted electrical nerve stimulator.

Electrical nerve stimulation for pain control may be considered medically necessary when the following criteria have been met:

For acute pain including post-operative pain the first 30-days from the day of surgery; or
For chronic pain, an individual is unresponsive to at least three (3) months of conservative therapy (i.e., non-steroidal anti-inflammatory medications, ice, rest and/or physical therapy); and
The individual is responsive to a trial of electrical stimulation for chronic pain control for at least two (2) weeks performed under medical supervision (i.e., physical therapy). For example, a demonstration of a reduction in pain that is clinically significant as defined by accepted documented outcome measures (i.e., pain scale); and
The trial period is monitored and documented by a licensed professional that is qualified to provide treatment (i.e., physical therapist).

The use of PENS and TENS not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer reviewed literature.

Procedure Codes

64555

64596

64597

64598

64999

A4595

E0720

E0730

Supplies for Electrical Stimulation Device

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.

Supplies for electrical stimulation device may be considered medically necessary when annual documentation is noted in the individual's medical record.

Normal utilization with a covered electrical stimulation device is:

For two (2) lead devices, four (4) electrodes per month; or
For four (4) lead devices, eight (8) electrodes per month.

Procedure code A4595 is allowed 12 every one (1) floating month.

Quantity of supplies that exceed the frequency guidelines listed on this policy are considered not medically necessary.

Procedure Codes

A4595

E0720

E0730

Phrenic Nerve Stimulator

The implantation of a United States Food and Drug Administration (U.S. FDA) approved phrenic nerve stimulator may be considered medically necessary:

The phrenic nerve is viable and intact; and
Diaphragmatic function is sufficient to accommodate chronic stimulation; and
For treatment of chronic ventilator or respiratory insufficiency requiring mechanical ventilation due to ONE (1) of the following conditions:
- Lesions/injury of the spinal cord at or above the C-3 vertebral level; or
- Central alveolar hypoventilation, either primary or secondary to a brain stem disorder; or
- Central sleep apnea (i.e., the Remede System) and central sleep related hypoventilation/hypoxemic syndromes.

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.

Phrenic nerve stimulation not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer reviewed literature.

Procedure Codes

33276

33277

33278

33279

33280

33281

33287

33288

64575

64580

64585

64590

64595

64596

64597

64598

64999

93150

93151

93152

93153

95970

95971

L8678

L8680

L8682

L8683

L8685

L8686

L8687

L8688

L8689

L8696

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.

Vagus Nerve Stimulator

The implantation of a vagus (vagal) nerve stimulator for seizure control may be considered medically necessary only when used as a last resort for individuals with epilepsy (aged four (4) years and older) with partial onset seizures who have not undergone a bilateral or left cervical vagotomy.

A U.S. FDA approved vagus nerve stimulator for the management of epilepsy with partial onset seizures may be considered medically necessary for individuals when seizures cannot be controlled by any other method, such as:

Drug-resistant epilepsy ('failure to control seizures with two (2) or more appropriately chosen drugs in adequate doses'); or
When surgery cannot be performed.

Vagus (vagal) nerve stimulation not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

61885

61886

64553

64568

64569

64570

95970

95976

95977

E1399

L8678

L8679

L8680

L8681

L8682

L8683

L8685

L8686

L8687

L8688

L8689

L8695

Policy Application

Non-Implantable Vagus Nerve Stimulator

U.S. FDA approved non-implantable vagus nerve stimulation devices (i.e. gammaCore) may be considered medically necessary for the abortive treatment of migraine or cluster headache under ALL of the following circumstances:

The individual is aged eighteen years or older; and
The individual has a diagnosis of migraine or cluster headache; and
The individual has failed or has contraindication or has intolerance to at least two (2) medications from each of the following categories: NSAIDS, Triptans, and Ergotamines; and
The individual must be re-evaluated in 30 days. In order to obtain renewal of the device, there must be documentation of significant efficacy in the medical record.

In order to maintain coverage for gammaCore, the following efficacy must be documented:

Reduction of pain from moderate or severe to mild or pain free within 60 minutes, without the use of rescue medicine, for at least 50 percent of attacks.

U.S. FDA approved non-implantable vagus nerve stimulation devices (i.e., gammaCore) may be considered medically necessary for the preventive treatment of migraine headache or for the acute treatment of pain associated with migraine headaches under ALL of the following circumstances:

The individual is aged between 12 to 17 years of age; and
The individual has a diagnosis of migraine; and
The individual has failed or has contraindication or has intolerance to at least two (2) medications from each of the following categories: NSAIDS, Triptans, and Ergotamines; and
The individual must be re-evaluated in 30 days. In order to obtain renewal of the device, there must be documentation of significant efficacy in the medical record.

In order to maintain coverage for gammaCore, the following efficacy must be documented:

Reduction of pain from moderate or severe to mild or pain free within 60 minutes, without the use of rescue medicine, for at least 50 percent of attacks.

Non-implantable stimulation devices not meeting the criteria as indicated in this policy are considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer reviewed literature.

Procedure Codes

E0735

E1399

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.

Percutaneous Neuromodulation Therapy

The use of a Percutaneous nerve field stimulator in opioid withdrawal treatment is considered experimental/investigational and therefore non-covered, because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

The use of Percutaneous neuromodulation therapy is considered experimental/investigational and therefore non-covered, because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Implantable Peripheral Nerve Stimulator

Implantable peripheral nerve stimulation to include temporary and permanent placement of neuromuscular neurostimulation electrodes, for the management of chronic pain is considered experimental/investigational; for ANY indications and therefore non-covered, because the safety and/or effectiveness of this service cannot be established by the available published peer reviewed literature.

Procedure Codes

64555

64580

64999

E1399

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.

Occipital Nerve Stimulation (ONS)

ONS is considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

61885

61886

64553

64555

64568

64569

64570

64999

L8678

L8680

L8681

L8682

L8683

L8685

L8686

L8687

L8688

L8689

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.

External Trigeminal Nerve Stimulation System

An external trigeminal nerve stimulation (eTNS) system is considered experimental/investigational and therefore non-covered, because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

A4541

E0733

Policy Application

External Upper Limb Tremor Stimulator

An external upper limb tremor stimulator is considered experimental/investigational and therefore non-covered, because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

A4542

E0734

Policy Application

Transcutaneous Electrical Modulation Pain Reprocessing Therapy

Transcutaneous electrical modulation pain reprocessing therapy (TEMPR) (i.e., scrambler therapy) is considered experimental/investigational and therefore non-covered, because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Code

0278T

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.

Restorative Neurostimulation Therapy

Implanted peripheral electric nerve stimulation (i.e., ReActiv8) for the treatment of low back pain is considered experimental/investigational and therefore non-covered, because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

64555

64575

64590

64999

L8679

L8680

L8681

L8683

L8688

Policy Application

Replacement batteries are not eligible for payment and therefore non-covered.

Procedure Code

A4630

Policy Application

Outpatient HCPCS (C Codes)

C1767

C1778

C1816

C1820

C1822

C1823

C1826

C1883

C1897

Diagnosis Codes

Covered Diagnosis Codes for Vagus Nerve Stimulation

61885; 61886; 64553; 64568; 64569; and 64570

G40.001

G40.009

G40.011

G40.019

G40.101

G40.109

G40.111

G40.119

G40.201

G40.209

G40.211

G40.219

G40.C01

G40.C09

G40.C11

G40.C19

Z45.42

Covered Diagnosis Codes for Non-implantable Vagus Nerve Stimulation (E0735) for individuals aged 18 or older

G43.001

G43.009

G43.011

G43.019

G43.101

G43.109

G43.111

G43.119

G44.011

G44.019

G44.021

G44.029

G44.001

G44.009

Covered Diagnosis Codes for Non-implantable Vagus Nerve Stimulation (E0735) for Individuals aged 12-17

G43.001

G43.009

G43.011

G43.019

G43.101

G43.109

G43.111

G43.119

Covered Diagnosis Codes for Phrenic Nerve Stimulation

33276; 33277; 33278; 33279; 33280; 33281; 33287; 33288; 93150; 93151; 93152; and 93153

G47.31

G47.34

G47.35

G47.36

G47.37

Non-Covered Diagnosis Codes for Restorative Neuromodulation Therapy

64555; 64575; 64590; 64999; L8679; L8680; L8681; L8683; and L8688

M62.5A2

M53.86

M53.87

M54.41

M54.42

M54.51

M54.59

M54.89

M62.85

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020

Removed Deep Brain Stimulation and made it, it's own policy

Internal Medical Policy Committee 11-19-2020 Revision of policy

Expanded indications; definitions of indications; and E/I statements; and
Removed Procedure Codes; and
Added Procedure Codes; and
Added Diagnosis codes: G47.31; G47.34; G47.35; G47.36; and G47.37 for Phrenic Nerve Stimulation (64575, 64580, 64585, 64590,64595, L8680, L8682, L8683, L8685, L8686, L8687, L8688, L8689, L8696, 0424T, 0425T, 0426T, 0427T, 0428T, 0429T, 0430T, 0431T, 0432T, 0433T, 0434T, 0435T, 0436T)

Internal Medical Policy Committee 1-19-2021 Coding update:

Removed procedure codes 64561 and 64581; and
Added procedure codes 64999

Internal Medical Policy Committee 3-17-2021 Coding update - Effective April 01, 2021

Added Procedure code K1020

Internal Medical Policy Committee 9-21-2021 Coding update Effective October 01, 2021 :

Added Procedure codes: 64555; 64999; 95976; E1399; and
Added Diagnosis codes: G43.001; G43.009; G43.011; G43.019; G43.101; G43.109; G43.111; G43.119; G44.021; G44.029; G44.001; and G44.009; and
Revised language for clarity

Internal Medical Policy Committee 11-23-2021

Added statement regarding PENFS device

Internal Medical Policy Committee 7-21-2022 Revision with Coding - Effective July 01, 2022

Added Procedure code 0720T

Revision that is Effective September 05, 2022
- Revision of criteria throughout policy
  - Added Procedure codes 0278T; 95977; K1016; K1017; L8679; and L8695
  - Added Diagnosis code Z45.42
  - Added s ubtitle ' Implantable Peripheral Nerve Stimulator'
    to that section of policy.

Internal Medical Policy Committee11-29-2022 Coding update -Effective January 01, 2023

Added Procedure code C1826

Internal Medical Policy Committee 3-23-2023 Coding update - Effective April 01, 2023

Added Procedure code L8678

Internal Medical Policy Committee 1-16-2024 Coding update - Effective January 01, 2024

Removed procedure codes 0424T, 0425T, 0426T, 0427T, 0428T, 0429T, 0430T, 0431T, 0432T, 0433T, 0434T, 0435T, 0436T, K1016, K1017, K1018, K1019, K1020; and
Added procedure codes 33276, 33277, 33278, 33279, 33280, 33281, 33287, 33288, 64596, 64597, 64598, 93150, 93151, 93152, 93153, A4541, A4542, E0733, E0734, E0735.
Removed section Remote Electrical Neuromodulation as it is now found in policy E-88 Nerivio - Effective March 04, 2024.

Internal Medical Policy Committee 3-19-2024 Revision with coding update - Effective May 06, 2024

Updated criteria; and
Removed sections Percutaneous Electrical Nerve Field Stimulator; and
Removed section Percutaneous Electrical Nerve Field Stimulator - see policy Z-108; and
Removed procedure code 0720T; and
Added Percutaneous Electrical Nerve Field Stimulator; and
Added non-covered diagnosis codes section for Restorative Neurostimulation Therapy; and
Added diagnosis codes M62.5A2; M56.83; M53.87; M54.41; M54.42; M54.51; M54.59; M54.89; and
Added Policy Application.

Internal Medical Policy Committee 9-17-2024 Revision with coding update - Effective October 01, 2024

Added Non-covered Diagnosis code M62.85

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: Z-7-057

Section: Miscellaneous

Effective Date: July 01, 2018

Revised Date: March 23, 2024

Revision Effective Date: May 06, 2024

Last Reviewed: March 19, 2024

Archived Date: September 30, 2024

Applies To: Commercial and Medicaid Expansion

Description

Electrical nerve stimulation is the use of electric current produced by a device to stimulate the nerves for therapeutic purposes.

Policy Application

For Date of Service (DOS): All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

*See below to determine whether the policy rules apply to initial and adjustment claims based on date of processing (DOP) or Date of Service (DOS).

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 service.

Electrical Nerve Stimulation, (Transcutaneous Electrical Nerve Stimulation (TENS) and Percutaneous Electrical Nerve Stimulation) (PENS)

Electrical nerve stimulation for pain control may be considered medically necessary when the following criteria have been met:

For acute pain including post-operative pain the first 30-days from the day of surgery; or
For chronic pain, an individual is unresponsive to at least three (3) months of conservative therapy (i.e., non-steroidal anti-inflammatory medications, ice, rest and/or physical therapy); and
The individual is responsive to a trial of electrical stimulation for chronic pain control for at least two (2) weeks performed under medical supervision (i.e., physical therapy). For example, a demonstration of a reduction in pain that is clinically significant as defined by accepted documented outcome measures (i.e., pain scale); and
The trial period is monitored and documented by a licensed professional that is qualified to provide treatment (i.e., physical therapist).

Procedure Codes

64555

64596

64597

64598

64999

A4595

E0720

E0730

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.

Supplies for Electrical Stimulation Device

Supplies for electrical stimulation device may be considered medically necessary when annual documentation is noted in the individual's medical record.

Normal utilization with a covered electrical stimulation device is:

For two (2) lead devices, four (4) electrodes per month; or
For four (4) lead devices, eight (8) electrodes per month.

Procedure code A4595 is allowed 12 every one (1) floating month.

Quantity of supplies that exceed the frequency guidelines listed on this policy are considered not medically necessary.

Procedure Codes

A4595

E0720

E0730

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.

Phrenic Nerve Stimulator

The implantation of a United States Food and Drug Administration (U.S. FDA) approved phrenic nerve stimulator may be considered medically necessary:

The phrenic nerve is viable and intact; and
Diaphragmatic function is sufficient to accommodate chronic stimulation; and
For treatment of chronic ventilator or respiratory insufficiency requiring mechanical ventilation due to ONE (1) of the following conditions:
- Lesions/injury of the spinal cord at or above the C-3 vertebral level; or
- Central alveolar hypoventilation, either primary or secondary to a brain stem disorder; or
- Central sleep apnea (i.e., the Remede System) and central sleep related hypoventilation/hypoxemic syndromes.

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.

Procedure Codes

33276

33277

33278

33279

33280

33281

33287

33288

64575

64580

64585

64590

64595

64596

64597

64598

64999

93150

93151

93152

93153

95970

95971

L8678

L8680

L8682

L8683

L8685

L8686

L8687

L8688

L8689

L8696

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.

Vagus Nerve Stimulator

Drug-resistant epilepsy ('failure to control seizures with two (2) or more appropriately chosen drugs in adequate doses'); or
When surgery cannot be performed.

Vagus (vagal) nerve stimulation not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

61885

61886

64553

64568

64569

64570

95970

95976

95977

E1399

L8678

L8679

L8680

L8681

L8682

L8683

L8685

L8686

L8687

L8688

L8689

L8695

Policy Application

Non-Implantable Vagus Nerve Stimulator

The individual is aged eighteen years or older; and
The individual has a diagnosis of migraine or cluster headache; and
The individual has failed or has contraindication or has intolerance to at least two (2) medications from each of the following categories: NSAIDS, Triptans, and Ergotamines; and
The individual must be re-evaluated in 30 days. In order to obtain renewal of the device, there must be documentation of significant efficacy in the medical record.

In order to maintain coverage for gammaCore, the following efficacy must be documented:

Reduction of pain from moderate or severe to mild or pain free within 60 minutes, without the use of rescue medicine, for at least 50 percent of attacks.

The individual is aged between 12 to 17 years of age; and
The individual has a diagnosis of migraine; and
The individual has failed or has contraindication or has intolerance to at least two (2) medications from each of the following categories: NSAIDS, Triptans, and Ergotamines; and
The individual must be re-evaluated in 30 days. In order to obtain renewal of the device, there must be documentation of significant efficacy in the medical record.

In order to maintain coverage for gammaCore, the following efficacy must be documented:

Reduction of pain from moderate or severe to mild or pain free within 60 minutes, without the use of rescue medicine, for at least 50 percent of attacks.

Procedure Codes

E0735

E1399

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.

Percutaneous Neuromodulation Therapy

Implantable Peripheral Nerve Stimulator

Procedure Codes

64555

64580

64999

E1399

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.

Occipital Nerve Stimulation (ONS)

Procedure Codes

61885

61886

64553

64555

64568

64569

64570

64999

L8678

L8680

L8681

L8682

L8683

L8685

L8686

L8687

L8688

L8689

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.

External Trigeminal Nerve Stimulation System

Procedure Codes

A4541

E0733

Policy Application

External Upper Limb Tremor Stimulator

Procedure Codes

A4542

E0734

Policy Application

Transcutaneous Electrical Modulation Pain Reprocessing Therapy

Procedure Code

0278T

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.

Restorative Neurostimulation Therapy

Procedure Codes

64555

64575

64590

64999

L8679

L8680

L8681

L8683

L8688

Policy Application

Replacement batteries are not eligible for payment and therefore non-covered.

Procedure Code

A4630

Policy Application

Outpatient HCPCS (C Codes)

C1767

C1778

C1816

C1820

C1822

C1823

C1826

C1883

C1897

Diagnosis Codes

Covered Diagnosis Codes for Vagus Nerve Stimulation

61885; 61886; 64553; 64568; 64569; and 64570

G40.001

G40.009

G40.011

G40.019

G40.101

G40.109

G40.111

G40.119

G40.201

G40.209

G40.211

G40.219

G40.C01

G40.C09

G40.C11

G40.C19

Z45.42

Covered Diagnosis Codes for Non-implantable Vagus Nerve Stimulation (E0735) for individuals aged 18 or older

G43.001

G43.009

G43.011

G43.019

G43.101

G43.109

G43.111

G43.119

G44.011

G44.019

G44.021

G44.029

G44.001

G44.009

Covered Diagnosis Codes for Non-implantable Vagus Nerve Stimulation (E0735) for Individuals aged 12-17

G43.001

G43.009

G43.011

G43.019

G43.101

G43.109

G43.111

G43.119

Covered Diagnosis Codes for Phrenic Nerve Stimulation

33276; 33277; 33278; 33279; 33280; 33281; 33287; 33288; 93150; 93151; 93152; and 93153

G47.31

G47.34

G47.35

G47.36

G47.37

Non-Covered Diagnosis Codes for Restorative Neuromodulation Therapy

64555; 64575,; 64590; 64999; L8679; L8680; L8681; L8683; and L8688

M62.5A2

M53.86

M53.87

M54.41

M54.42

M54.51

M54.59

M54.89

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020

Removed Deep Brain Stimulation and made it, it's own policy

Internal Medical Policy Committee 11-19-2020 Revision of policy

Expanded indications; definitions of indications; and E/I statements; and
Removed Procedure Codes; and
Added Procedure Codes; and
Added Diagnosis codes: G47.31; G47.34; G47.35; G47.36; and G47.37 for Phrenic Nerve Stimulation (64575, 64580, 64585, 64590,64595, L8680, L8682, L8683, L8685, L8686, L8687, L8688, L8689, L8696, 0424T, 0425T, 0426T, 0427T, 0428T, 0429T, 0430T, 0431T, 0432T, 0433T, 0434T, 0435T, 0436T)

Internal Medical Policy Committee 1-19-2021 Coding update:

Removed procedure codes 64561 and 64581; and
Added procedure codes 64999

Internal Medical Policy Committee 3-17-2021 Coding update - Effective April 01, 2021

Added Procedure code K1020

Internal Medical Policy Committee 9-21-2021 Coding update Effective October 01, 2021 :

Added Procedure codes: 64555; 64999; 95976; E1399; and
Added Diagnosis codes: G43.001; G43.009; G43.011; G43.019; G43.101; G43.109; G43.111; G43.119; G44.021; G44.029; G44.001; and G44.009; and
Revised language for clarity

Internal Medical Policy Committee 11-23-2021

Added statement regarding PENFS device

Internal Medical Policy Committee 7-21-2022 Revision with Coding - Effective July 01, 2022

Added Procedure code 0720T

Revision that is Effective September 05, 2022
- Revision of criteria throughout policy
  - Added Procedure codes 0278T; 95977; K1016; K1017; L8679; and L8695
  - Added Diagnosis code Z45.42
  - Added s ubtitle ' Implantable Peripheral Nerve Stimulator'
    to that section of policy.

Internal Medical Policy Committee11-29-2022 Coding update -Effective January 01, 2023

AddedProcedure code C1826

Internal Medical Policy Committee 3-23-2023 Coding update - Effective April 01, 2023

Added Procedure code L8678

Internal Medical Policy Committee 1-16-2024 Coding update - Effective January 01, 2024

Removed procedure codes 0424T, 0425T, 0426T, 0427T, 0428T, 0429T, 0430T, 0431T, 0432T, 0433T, 0434T, 0435T, 0436T, K1016, K1017, K1018, K1019, K1020; and
Added procedure codes 33276, 33277, 33278, 33279, 33280, 33281, 33287, 33288, 64596, 64597, 64598, 93150, 93151, 93152, 93153, A4541,A4542, E0733, E0734, E0735.
Removed section Remote Electrical Neuromodulation as it is now found in policy E-88 Nerivio - Effective March 04, 2024.

Internal Medical Policy Committee 3-19-2024 Revision with coding update - Effective May 06, 2024

Updated criteria; and
Removed sections Percutaneous Electrical Nerve Field Stimulator; and
Removed section Percutaneous Electrical Nerve Field Stimulator - see policy Z-108; and
Removed procedure code 0720T; and
Added Percutaneous Electrical Nerve Field Stimulator; and
Added non-covered diagnosis codes section for Restorative Neurostimulation Therapy; and
Added diagnosis codes M62.5A2; M56.83; M53.87; M54.41; M54.42; M54.51; M54.59; M54.89; and
Added Policy Application.

Medical Policies Quick Search

Electrical Nerve Stimulation

Description

Policy Application

Criteria

Electrical Nerve Stimulation, (Transcutaneous Electrical Nerve Stimulation (TENS) and Percutaneous Electrical Nerve Stimulation) (PENS)

Policy Application

Procedure Codes

Supplies for Electrical Stimulation Device

Policy Application

Procedure Codes

Phrenic Nerve Stimulator

Policy Application

Procedure Codes

Policy Application

Vagus Nerve Stimulator

Procedure Codes

Policy Application

Non-Implantable Vagus Nerve Stimulator

Procedure Codes

Policy Application

Percutaneous Neuromodulation Therapy

Implantable Peripheral Nerve Stimulator

Procedure Codes

Policy Application

Occipital Nerve Stimulation (ONS)

Procedure Codes

Policy Application

External Trigeminal Nerve Stimulation System

Policy Application

External Upper Limb Tremor Stimulator

Policy Application

Transcutaneous Electrical Modulation Pain Reprocessing Therapy

Policy Application

Restorative Neurostimulation Therapy

Policy Application

Policy Application

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Description

Policy Application

Criteria

Policy Application

Electrical Nerve Stimulation, (Transcutaneous Electrical Nerve Stimulation (TENS) and Percutaneous Electrical Nerve Stimulation) (PENS)

Procedure Codes

Policy Application

Supplies for Electrical Stimulation Device

Procedure Codes

Policy Application

Phrenic Nerve Stimulator

Policy Application

Procedure Codes

Policy Application

Vagus Nerve Stimulator

Procedure Codes

Policy Application

Non-Implantable Vagus Nerve Stimulator

Procedure Codes

Policy Application

Percutaneous Neuromodulation Therapy

Implantable Peripheral Nerve Stimulator

Procedure Codes

Policy Application

Occipital Nerve Stimulation (ONS)

Procedure Codes

Policy Application

External Trigeminal Nerve Stimulation System

Policy Application

External Upper Limb Tremor Stimulator

Policy Application

Transcutaneous Electrical Modulation Pain Reprocessing Therapy

Policy Application

Restorative Neurostimulation Therapy

Policy Application

Policy Application

Outpatient HCPCS (C Codes)