Percutaneous Electrical Nerve Field Stimulation (PENFS)

Policy ID: Z-108-001

Section: Miscellaneous

Effective Date: May 06, 2024

Last Reviewed: March 19, 2024

Applies To: Commercial and Medicaid Expansion

Description

Percutaneous electrical nerve field stimulation (PENFS) involves the transmission of electrical impulses to cranial nerve bundles in the ear targeting brain areas involved in processing pain. In PENFS for irritable bowel syndrome (IBS), nerves processing pain for the abdominal region are targeted via a stimulator placed behind the ear.

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

Percutaneous electrical nerve field stimulation (PENFS) for the treatment of functional abdominal pain may be considered medically necessary when ALL of the following criteria are met:

Individuals 11-18 years of age; and
Individual is diagnosed with Irritable Bowel Syndrome (IBS); and
The device is prescribed by a pediatric gastroenterologist; and
The device is U.S. FDA approved (i.e., IB-Stim); and
The individual has tried and failed standard of care IBS treatments (e.g. medication, psychotherapy); and
The device will not be worn for more than 120 hours over three (3) consecutive weeks; and
The individual does not have ANY of the following contraindications:
- psoriasis or other skin condition affecting the skin behind the ear; or
- hemophilia; or
- cardiac pacemaker.

Percutaneous electrical nerve field stimulation (PENFS) 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 Code

0720T

Diagnosis Codes

K58.0

K58.1

K58.2

K58.8

K58.9

R10.33

R10.84

R10.9

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 3-19-2024 New Policy - Effective May 06, 2024

Adopted policy; and
Added Policy Application

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.

Our Partners in Health:
Members
Employers
Producers

Fargo (Headquarters)
4510 13th Ave. S.
Fargo, N.D., 58121

Medical Policies Quick Search