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.
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 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
64555 | 64561 | 64581 | 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:
Procedure Codes
A4595 | E0720 | E0730 |
Phrenic nerve stimulator implantation may be considered medically necessary:
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
64999 | L8680 | L8682 | L8683 |
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
61885 | 61886 | 64553 | 64568 | 64569 | 64570 | 95970 |
E1399 | L8680 | L8681 | L8682 | L8683 | L8685 | L8686 |
L8687 | L8688 | L8689 |
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:
In order to maintain coverage for gammaCore, the following efficacy must be documented:
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
E1399 |
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
64580 | 64999 | 95971 | 95972 | L8680 | L8681 | L8682 |
L8683 | L8685 | L8686 | L8687 | L8688 | L8689 |
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
61885 | 61886 | 64553 | 64555 | 64568 | 64569 | 64570 |
64575 | 64999 | L8680 | L8681 | L8682 | L8683 | L8685 |
L8686 | L8687 | L8688 | L8689 |
Replacement batteries are not eligible for benefits and therefore non-covered.
Procedure Codes
A4630 |
Outpatient HCPCS (C Codes)
C1767 | C1778 | C1816 | C1820 | C1822 | C1823 | C1883 |
C1897 |
Diagnosis Codes
Covered Diagnosis Codes
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 |
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 |
NA