Electrical Nerve Stimulation

Policy ID: Z-7-047

Section: Miscellaneous

Effective Date: July 01, 2018

Revised Date: March 15, 2021

Revision Effective Date: April 01, 2021

Last Reviewed: March 17, 2021

Description

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

Criteria

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 thirty (30) days from the day of surgery; or
For chronic pain, an individual is unresponsive to at least three (3) months of conservative therapy (e.g., 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 (e.g., physical therapy). For example, a demonstration of a reduction in pain that is clinically significant as defined by accepted documented outcome measures (e.g., pain scale); and
The trial period is monitored and documented by a licensed professional that is qualified to provide treatment (e.g., physical therapist).

The use of PENS and TENS for conditions not listed above 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

64999

A4595

E0720

E0730

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 Codes

A4595

E0720

E0730

Phrenic Nerve Stimulator

Phrenic nerve stimulator implantation may be considered medically necessary:

For treatment of chronic ventilator or respiratory insufficiency requiring mechanical ventilation due to:
- 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 (e.g. the Remede System) and central sleep related hypoventilation/hypoxemic syndromes; and
The phrenic nerve is viable and intact; and
Diaphragmatic function is sufficient to accommodate chronic stimulation.

The use of phrenic nerve stimulation for ANY other indication 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

64575	64580	64585	64590	64595	64999	L8680
L8682	L8683	L8685	L8686	L8687	L8688	L8689
L8696	0424T	0425T	0426T	0427T	0428T	0429T
0430T	0431T	0432T	0433T	0434T	0435T	0436T

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 with partial onset seizures.

Medical necessity is limited to those cases where the 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.

The use of vagus (vagal) nerve stimulation for ANY other indication 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	64568	64569	64570	95970
E1399	L8680	L8681	L8682	L8683	L8685	L8686
L8687	L8688	L8689

Non-implantable vagus nerve stimulation devices (e.g., gammaCore) may be considered medically necessary for the abortive treatment of episodic migraine or episodic cluster headache under ALL of the following circumstances:

The individual has a diagnosis of episodic migraine or episodic 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% of attacks.

Non-implantable stimulation devices are considered experimental/investigational for ANY other indications and circumstances except those outlined above 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

E1399

K1020

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.

Procedure Codes

64999

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

Occipital Nerve Stimulation (ONS)

ONS is considered experimental/investigational for ALL 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

61885	61886	64553	64555	64568	64569	64570
64999	L8680	L8681	L8682	L8683	L8685	L8686
L8687	L8688	L8689

Outpatient HCPCS (C Codes)

C1767	C1778	C1816	C1820	C1822	C1823	C1883
C1897

Diagnosis Codes

Covered Diagnosis Codes for Vagus Nerve Stimulation: 61885, 61886, 64553, 64568, 64569, 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

Covered Diagnosis Codes for Non-implantable Vagus Nerve Stimulation: E1399, K1020

G43.001	G43.009	G43.011	G43.019	G43.101	G43.109	G43.111
G43.119	G44.011	G44.019

Covered Diagnosis Codes 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

G47.31

G47.34

G47.35

G47.36

G47.37

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

Expanding indications and expanding definitions of indications; expanded E/I statements
Removed Procedure Codes
Added Procedure Codes
Added Diagnosis codes: G47.31; G47.34; G47.35; G47.36; and G47.37for 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;
Added procedure codes 64999

Internal Medical Policy Committee 3-17-2021 Coding update: Added K1020 Effective April 1, 2021

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-7-046

Section: Miscellaneous

Effective Date: July 01, 2018

Revised Date: January 14, 2021

Revision Effective Date: January 04, 2021

Last Reviewed: January 19, 2021

Archived Date: March 31, 2021

Description

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

Criteria

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 thirty (30) days from the day of surgery; or
For chronic pain, an individual is unresponsive to at least three (3) months of conservative therapy (e.g., 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 (e.g., physical therapy). For example, a demonstration of a reduction in pain that is clinically significant as defined by accepted documented outcome measures (e.g., pain scale); and
The trial period is monitored and documented by a licensed professional that is qualified to provide treatment (e.g., physical therapist).

Procedure Codes

64555

64999

A4595

E0720

E0730

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 device, four (4) electrodes per month; or
For four (4) lead device, eight (8) electrodes per month.

Procedure Codes

A4595

E0720

E0730

Phrenic Nerve Stimulator

Phrenic nerve stimulator implantation may be considered medically necessary:

For treatment of chronic ventilator or respiratory insufficiency requiring mechanical ventilation due to:
- 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 (e.g. the Remede System) and central sleep related hypoventilation/hypoxemic syndromes; and
The phrenic nerve is viable and intact; and
Diaphragmatic function is sufficient to accommodate chronic stimulation.

Procedure Codes

64575	64580	64585	64590	64595	64999	L8680
L8682	L8683	L8685	L8686	L8687	L8688	L8689
L8696	0424T	0425T	0426T	0427T	0428T	0429T
0430T	0431T	0432T	0433T	0434T	0435T	0436T

Vagus Nerve Stimulator

Medical necessity is limited to those cases where the 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

Procedure Codes

61885	61886	64553	64568	64569	64570	95970
E1399	L8680	L8681	L8682	L8683	L8685	L8686
L8687	L8688	L8689

The individual has a diagnosis of episodic migraine or episodic 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% of attacks.

Procedure Code

E1399

Procedure Codes

64999

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

Occipital NerveStimulation (ONS)

Procedure Codes

61885	61886	64553	64555	64568	64569	64570
64999	L8680	L8681	L8682	L8683	L8685	L8686
L8687	L8688	L8689

Outpatient HCPCS (C Codes)

C1767	C1778	C1816	C1820	C1822	C1823	C1883
C1897

Covered Diagnosis Codes for Vagus Nerve Stimulation: 61885, 61886, 64553, 64568, 64569, 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

Covered Diagnosis Codes for Non-implantable Vagus Nerve Stimulation: E1399

G43.001	G43.009	G43.011	G43.019	G43.101	G43.109	G43.111
G43.119	G44.011	G44.019

G47.31

G47.34

G47.35

G47.36

G47.37

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

Expanding indications and expanding definitions of indications; expanded E/I statements
Removed Procedure Codes
Added Procedure Codes
Added Diagnosis codes: G47.31; G47.34; G47.35; G47.36; and G47.37for 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;
Added procedure codes 64999

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.

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