Electrical/Magnetic Neuro Stimulators

Medical Policy: 01.01.06 
Original Effective Date: November 2000 
Reviewed: January 2012 
Revised: February 2011 

Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary based on contract, and individual member benefits must be verified. Wellmark determines medical necessity only if the benefit exists and no contract exclusions are applicable. This medical policy may not apply to FEP. Benefits are determined by the Federal Employee Program.

This Medical Policy document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy will be reviewed regularly and be updated as scientific and medical literature becomes available.

Description: 

TENS: Transcutaneous Electrical Nerve stimulator is a device used to treat chronic intractable pain, and pain associated with active or post- traumatic injury unresponsive to other standard pain therapies. The device is applied to the surface of the skin at the site of the pain. It consists of an electrical pulse generator, usually battery operated, connected by a wire to two or more electrodes. A programmable stimulator may be programmed in advance to stimulate at regular times or upon demand by the use of a hand held magnet over the stimulator. ( Neuro Cybernetic Prosthesis System )

MNS: Microcurrent Nerve Stimulator works on the same principal as TENS by delivering microcurrent instead of regular current.

PENS: Percutaneous Nerve Stimulator is similar to TENS, with the exception that instead of electrodes attached to the skin near the pain area, in PENS, a needle is inserted into the pain site.

PNT:  Percutaneous neuromodulation therapy is a variant of PENS in which up to 10 fine filament electrodes are temporarily placed at specific anatomical landmarks in the back.  Treatment regimens consist of 30-minute sessions, once or twice a week for 8 to 10 sessions.

VNS: Implanted vagus nerve stimulation (VNS) devices have been used to treat patients with medically refractory partial-onset seizures for whom surgery is not recommended or for whom surgery has failed. Surgery for implantation of the VNS device is done with the patient under either general anesthesia or regional cervical block. Since right vagus nerve stimulation produces bradycardia, implantation is limited to left-sided unilateral implantations. Two spiral electrodes are implanted around the left vagus nerve within the carotid sheath, which are connected to an infraclavicular generator pack. A programmable stimulator may be programmed in advance to stimulate at regular times or upon demand by the use of a hand held magnet over the stimulator. ( Neuro Cybernetic Prosthesis System )

FNS: Functional Neuromuscular Stimulation attempts to replace stimuli from destroyed nerve pathways with electrical stimulation to the muscles. It is presumed that electric stimulation enables the spinal cord injured patient to stand or walk independently, or to maintain healthy muscle tone and strength.

NMES: Neuromuscular Electric Stimulator for disuse atrophy.  NMES involves the use of a device that transmits an electrical impulse to activate muscle groups by way of electrodes.  There are two broad categories of NMES.  One type of device stimulates the muscle when the patient is in a resting state to treat muscle atrophy.  The second type is used to enhance functional activity of neurologically impaired patients.

Spinal Cord Stimulation for Chronic Pain:  Electrodes are implanted in the epidural space to stimulate the dorsal column and treat chronic pain.

DBS: Deep Brain Stimulation of the thalamus has been used as an alternative to permanent neuroablative procedures such as thalamotomy and pallidotomy for control of essential tremor, and tremors associated with Parkinson's disease.  It involves stereotactic placement of an electrode into the brain, which is attached to a temporary transcutaneous cable for short-term stimulation to validate treatment effectiveness.  Several days later a permanent subcutaneous programmable stimulator is implanted.  DBS of the globus pallidus and subthalamic nucleus has also been investigated for other symptoms of Parkinson's disease such as rigidity, bradykinesia or akinesia.  DBS is also FDA approved for the treatment of dystonia.

H-Wave® Electric Stimulation: This device is used for the treatment of pain related to a variety of etiologies.  This is also used for wound healing.

Sensory Stimulation for Coma Patients: Sensory stimulation is intended to enhance awakening and rehabilitative potential of coma patients.  Treatment may be delivered in the hospital, the patient's home, or a nursing home by professionals including nurses, occupational therapist, physical therapist, speech language therapist and even by a trained family member.

TES: Threshold Electric Stimulator as a treatment of motor disorders. Low intensity electrical stimulation is used to target spastic muscles during sleep at home. Although the exact mechanism of action is not known, it is presumed that it may increase muscle strength and joint mobility leading to improved voluntary motor function. This is used in children with spastic paraplegia related to cerebral palsy and also in those with other motor disorders, such as spina bifida.

Sympathetic therapy as a treatment of chronic pain (i.e. Dynatron STS): Sympathetic therapy describes a type of electrical stimulation of the peripheral nerves that is designed to stimulate the sympathetic nervous system in an effort to 'normalize' the autonomic nervous system and alleviate chronic pain.  Sympathetic therapy is not designed to treat local pain, but is designed to induce a systemic effect on sympathetically induced pain.

Interferential current stimulation (IFC) is a type of electrical current treatment that uses paired electrodes of two independent medium-frequency alternating currents. The electrodes are arranged on the skin so the current flowing between each pair intersects at the underlying target. IFC has been investigated as a technique to reduce pain, improve range of motion, or promote local healing.

Lymphavision^TM is an electrical stimulation device that stimulates smooth muscles thereby promoting lymphatic flow. It is described as a treatment for such conditions as diabetic foot syndrome and trophic ulcers, and prevention of deep vein thrombosis.

TEJS: Transcutaneous electrical joint stimulation is the application of a signal-specific electrical current to the joint tissue to relive the signs and symptoms of osteoarthritis of the knee. Two electrode patches are worn for six to ten hours a day, preferably while the patient is sleeping. TEJS has been indicated as adjunctive therapy for patients who have failed NSAIDS, those with moderate to severe disease despite best medical therapy, and those with severe disease who are not surgical candidates for reasons such as morbid obesity and inappropriate age.

PES: Pulsed electrical stimulation is provided by an electronic device that noninvasively delivers a low voltage, monophasic electrical field to the targeted area of pain. It is used to improve functional status and relieve pain related to osteoarthritis and rheumatoid arthritis unresponsive to other standard forms of treatment.

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Prior Approval: 

Not applicable

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Policy: 

• TENS, MNS, PENS may be considered medically necessary for the treatment of chronic intractable pain and acute postoperative pain.
• VNS may be considered medically necessary for the treatment of patients with medically refractory partial-onset seizures.
• VNS is considered investigational for the treatment of all other conditions, including but not limited to, treatment resistant depression, essential tremor, and headaches.
• FNS may be considered medically necessary or the following indications: 
  • Brachial plexopathy/lumbosacral plexopathy
  • Decrease spasticity
  • Diabetic neuropathy
  • Guillain-Barré Syndrome other peripheral nerve injuries
  • Initiate return of lost functional movement
  • Laminectomy with lower extremity motor loss strengthening of innervated muscles
  • Multiple sclerosis
  • Patellofemoral syndrome
  • Post cerebrovascular accident
  • Post incomplete spinal cord injury
  • Post knee arthroscopy
  • Post polio
  • Post traumatic brain injury
• NMES may be considered medically necessary for disuse atrophy when the nerve supply to the muscle is intact and the patient has non-neurological reasons for disuse atrophy. 
• Spinal Cord Stimulation may be considered medically necessary for chronic reflex sympathetic dystrophy (RSD) and severe and chronic pain refractory to all other pain therapies.  
• Deep Brain Stimulation may be considered medically necessary for disabling, unresponsive tremor due to:
  • essential tremors or
  • Parkinson's disease, or
  • primary dystonia refractory to medical treatment.
• Deep brain stimulation for other movement disorders, including but not limited to multiple sclerosis, post-traumatic dyskinesia, and tardive dyskinesia, is considered investigational.
• Deep brain stimulation for the treatment of other psychiatric or neurologic disorders, including but not limited to Tourette Syndrome, depression, obsessive compulsive disorder and epilepsy, is considered investigational. 
• H-Wave® Electric Stimulator is considered investigational for the treatment of pain related to etiologies such as diabetic neuropathy, muscle sprains, temporomandibular joint dysfunction or reflex sympathetic dystrophy, and also when used to accelerate healing of wounds.
• Sensory Stimulation for coma patients is considered investigational.
• TES  is considered investigational for motor disorders, including but not limited to cerebral palsy.
• Sympathetic therapy for treatment of pain  (Dynatron STS) is considered investigational in the peer-reviewed literature regarding this therapy.
• Lymphavison^TM electrical muscle stimulator is considered investigational due to the lack of peer reviewed scientific literature supporting its safety and efficacy.
• PNT considered investigational for all applications.
• IFC is considered investigational for all applications.
• TEJS is considered investigational for all applications including as a treatment of osteoarthritis.
• PES is considered investigational for all applications 

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Procedure Codes and Billing Guidelines: 

• To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
• TENS HCPCS codes E0720, E0730, E0731, A4595 and A4630 and CPT code 64550.
• PENS CPT code 64999
• FNS  HCPCS E0764 Functional neuromuscular stimulation, transcutaneous stimulation of sequential muscle groups of ambulation with computer control, used for walking by spinal cord injured, entire system, after completion of training program. HCPCS E0770 Functional electrical stimulator, transcutaneous stimulation of nerve and/or muscle groups, any type, complete system, not otherwise specified
• NMES HCPCS E0745. 
• Vagus Nerve Stimulation (VNS) providers may use CPT codes 95970, 95971, 95972, 95973, 95974, 95975, 61885, 61886, L8680, 64573
• Deep Brain Stimulation (DBS) a series of the following CPT codes describing various steps of the procedure may be used:  61850 through 61888.
• 95978 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour
• 95979 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; each additional 30 minutes after first hour (List separately in addition to code for primary procedure)  
  95970: For postoperative electronic analysis of implanted neurostimulator pulse generator system without reprogramming.
• 95971-95973: For intraoperative or subsequent neurostimulator analysis and  programming that is classified as simple (95971) or complex and time based (95972-73). Consult the most recent CPT manual for specific definitions of simple, complex and time based codes. 
• Spinal Cord Stimulation:  A series of the following CPT codes describing various steps of the procedure may be used:
  95970, 95971, 95972 & 95973: for electronic analysis of implanted neurostimulator.
  Use CPT codes 63650, 63655 and 63685: for implantation of electrodes.
• TEJS: HCPCS code E0762 Transcutaneous electrical joint stimulation device system, includes all accessories
• PES: HCPCS code E0762 Transcutaneous electrical joint stimulation device system, includes all accessories

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Selected References: 

• Hooker, SP, et al. Physiologic response to prolonged electrically stimulated leg-cycle exercise in the spinal cord injured. Archives of Physical Medicine and Rehabilitation 1990; vol 71: 863-869.
• BeDell, KK, et al. Effects of functional electrical stimulation-induced lower extremity cycling on bone density of spinal cord-injured patients. American Journal of Physical Medicine and Rehabilitation, 1996; 75:29-34.
• Oh M, Whiting D. Minimally invasive peripheral nerve stimulation for the treatment of occipital neuralgia.   American Association of Neurological Surgeons Pain News 1999;6(2):3-5
• Ghoname EA, Craig WF, White PF et al.  Percutaneous electrical nerve stimulation for low back pain:  a randomized crossover study. JAMA 1999;281(9):818-23.
• Condon JE, Borg-Stein J. Revord J et al.  A multicenter trial of percutaneous neuromodulation therapy for low back pain patients with a subacute duration of lower extremity pain.  Presented at the American Academy of Pain Medicine Annual Meeting.  San Francisco, CA March 1,2002.
• Minder PM, Noble JG, Alves-Guerreiro J, Hill ID, Lowe AS, Walsh DM, Baxter GD.  Interferential therapy:  lack of effect upon experimentally induced delayed onset muscle soreness.  Clin Physiol Funct Imaging.  2002 Sep;22 (5): 339-47.
• Palmer ST, Martin DJ, Steedman WM, Ravey J.  Effects of electric stimulation on C and A delta fiber-mediated thermal perception thresholds.  Arch Phys Med Rehabil. 2004 Jan;85(1):119-28.
• Yan T, Hui-Chan CW, Li LS. Functional electrical stimulation improves motor recovery of the lower extremity and walking ability of subjects with first acute stroke: a randomized placebo-controlled trial. Stroke 2005;36(1):80-5.
• Zizic TM, Hoffman KC, Holt PA et al. The treatment of osteoarthritis of the knee with pulsed electrical stimulation. J Rehumatol 995 Spe;22(9):1757-61.
• Dieppe PA, Lohmander LS. Pathogenesis and management of pain in osteoarthritis. Lancet 2005 Mar 12-18;365(9463):965-73.
• Farr j Mont m Farland D et al; Pulsed Electrical Stimulation in patients with osteoarthritis. Surg Tech Internatl 2006; 15: 227-33.
• ECRI. Interferential Current Therapy for Low-back Pain. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2007 August 7. 9p. (ECRI Hotline Response). Also available: http://www.ecri.org.
• ECRI. Interferential Current Therapy for Conditions Other Than Low-back Pain. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2007 August 9.  8 p. (ECRI Hotline Response). Also available: http://www.ecri.org.
• ECRI. Transcutaneous Electrical Nerve Stimulation for Knee Osteoarthritis. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2007 August 16. 9 p. (ECRI Hotline Response). Also available: http://www.ecri.org.
• ECRI. Transcutaneous Electrical Nerve Stimulation for Back Pain. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2008 February 5.  12 p. (ECRI Hotline Response). Also available: http://www.ecri.org.
• ECRI. Rechargeable Spinal Cord Stimulation Systems for Chronic Pain Control. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2008 March 20. 11 p. (ECRI Hotline Response). Also available: http://www.ecri.org.
• ECRI. Neuromuscular Electrical Stimulation for Hemiplgia. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2008 October 10.  16 p. (ECRI Hotline Response). Also available: http://www.ecri.org
• Dubinsky RM, Miyasaki J. Assessment: Efficacy of transcutaneous electric nerve stimulation in the treatment of pain in neurologic disorders (an evidence-based review). Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2010 Jan 12; 74(2): 173-6.

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Policy History: 

Date                                        Reason                               Action

October 2010                         Annual review                     Policy renewed

February 2011                       Interim review                      Policy revised

January 2012                         Annual review                     Policy renewed

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Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc.   They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.

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