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

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

• Chronic intractable pain is defined as chronic pain that has no significant chance of being altered by usual treatment modalities or natural healing.  Examples of chronic intractable are as follows:
  • An episode of low back pain that has persisted for three (3) months or longer; and
  • Is not a manifestation of a clearly defined and generally recognizable primary disease entity. For example, there are cancers that, through metastatic spread to the spine or pelvis, may elicit pain in the lower back as a symptom; and certain systemic diseases such as rheumatoid arthritis and multiple sclerosis manifest many debilitating symptoms.

TENS may be considered medically necessary when the chronic intractable pain causes significant disruption of function when ALL of the following have been met:

• The individual is unresponsive to at least three (3) months of conservative medical therapy (e.g., non-steroidal anti-inflammatory medications, ice, rest and/or physical therapy); and
• The individual is responsive to a trial of TENS 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 other than chronic intractable pain is considered experimental/investigational and therefore non-covered. Scientific evidence does not support its use for any other indications.

Procedure Codes

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
• For four (4) lead device, eight (8) electrodes per month

Procedure Codes

Phrenic nerve stimulator implantation may be considered medically necessary:

• For treatment of chronic ventilator or respiratory insufficiency requiring mechanical ventilation due to either:
  • 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
• 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. Scientific evidence does not support its use for any other indications.

Procedure Codes

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, i.e., surgery or medication.

The use of vagus (vagal) nerve stimulation for ANY other indication is considered experimental/investigational and therefore non-covered. Scientific evidence does not support its use for any other indications.

Procedure Codes

Nonimplantable 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 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.

Nonimplantable stimulation devices are considered experimental/investigational for ANY other indications and circumstances except those outlined above and therefore non-covered. Scientific evidence does not support its use for any other indications.

Procedure Code

The percutaneous or open (via incision) implantation of neuromuscular neurostimulator electrodes for chronic pain relief is considered experimental/investigational for ANY indications and therefore non-covered.

Scientific evidence does not support its use for any indications.

Procedure Codes

Occipital nerve stimulation (ONS) is considered experimental/investigational for ALL indications, and therefore, non-covered. Scientific evidence does not support its use for any indication.

Procedure Codes

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

Procedure Codes

Outpatient HCPCS (C Codes)

Diagnosis Codes

Covered Diagnosis Codes

Vagus Nerve Stimulation: 61885, 61886, 64553, 64568, 64569 and 64570

Non-implantable Vagus Nerve Stimulation: E1399

Professional Statements and Societal Positions Guidelines

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