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Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT)

» Summary» Procedure Codes
» Description» Selected References
» Prior Approval» Policy History
» Policy
 

Medical Policy: 01.01.21 
Original Effective Date: November 2000 
Reviewed: November 2014 
Revised: November 2014 


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: 

Percutaneous Electrical Nerve Stimulation (PENS)

 

Percutaneous electrical nerve stimulation (PENS) is similar in concept to transcutaneous electrical nerve stimulation (TENS), but differs in that needles are inserted either around or immediately adjacent to the nerves serving the painful area and are then stimulated.

 

PENS is generally reserved for patients who fail to get pain relief from TENS. PENS is also distinguished from acupuncture with electrical stimulation. In electrical acupuncture, needles are also inserted just below the skin, but the placement of needles is based on specific theories regarding energy flow throughout the human body. In PENS, the location of stimulation is determined by proximity to the pain rather than the theories of energy flow that guide placement of stimulation for acupuncture.

 

Percutaneous Neuromodulation Therapy (PNT)

 

Percutaneous neuromodulation therapy (PNT) is a variant of PENS in which fine filament electrode arrays are placed near the area that is causing pain. Some use the terms PENS and PNT interchangeably. It is proposed that PNT inhibits pain transmission by creating an electrical field that hyperpolarizes C-fibers, thus preventing action potential propagation along the pain pathway.

 

PENS is performed with a few needle electrodes while PNT uses very fine needle-like electrode arrays that are placed in close proximity to the painful area to stimulate peripheral sensory nerves in the soft tissue.


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Prior Approval: 

Not applicable.


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Policy: 

Percutaneous Electrical Nerve Stimulation (PENS)
Percutaneous electrical nerve stimulation (PENS) may be considered medically necessary for up to 30 days for the treatment of chronic intractable pain as part of the overall treatment plan and acute postoperative pain.

 

The 30 day timeframe would ensure the positive value and suitability of nerve stimulation for the patient. At that time the plan to continue stimulation would need to move to a modality available in the outpatient setting.

 

Based on peer reviewed literature percutaneous electrical nerve stimulation (PENS) for all other indications would be considered investigational as the effectiveness on health outcomes has not been established.

 

Percutaneous Neuromodulation Therapy (PNT)
Percutaneous Neuromodulation Therapy (PNT) is considered investigational for all indications.

 

Based on peer reviewed literature only 2 small trials were identified, the clinical input on the efficacy of PNT was mixed and the effect on health outcomes is uncertain. Therefore, percutaneous neurmodulation therapy (PNT) is considered investigational for all indications.  

 

The Centers for Medicare and Medicaid Services (CMS) currently has the following national coverage policy on diagnostic use of PENS:

  • Generally the physician should be able to determine whether the patient is likely to derive a significant therapeutic benefit from continuing use of an implanted nerve stimulator within a trial period of 1 month. 




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Procedure Codes and Billing Guidelines: 

  • To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.
  • 64999 Unlisted procedure, nervous system
  • E1399 Durable medical equipment, miscellaneous

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Selected References: 

Wellmark's policy is based on:

  • CMS. National Coverage Determination. Electrical Nerve Stimulation Therapy (160.7.1).
  • JAMA. Percutaneous Electrical Nerve Stimulation for Low Back Pain. March 3, 1999. Vol 281, No 9.
  • International Association for the Study of Pain. Efficacy of Electrical Nerve Stimulation for Chronic Musculoskeletal Pain: A Meta-Analysis of Randomized Controlled Trials. Doi:10.1016/j.pain.2007.02.007
  • Practice Guidelines for Chronic Pain Management. An Updated Report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology, V 112. No 4. April 2010.
  • National Guideline Clearinghouse. Guideline Summary NGC-8504. Evidence Based Guideline: Treatment of Painful Diabetic Neuropathy. Report on the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation. Neurology. 2011 May 17;76(20):1758-65.
  • National Institute for Health and Clinical Excellence (NICE). Percutaneous Electrical Nerve Stimulation for Refractory Neuropathic Pain. Issued March 2013 
  • ECRI. Hotline Response. Implantable Peripheral Nerve Stimulation Devices for Treating Chronic Pain. March 2013.
  • UpToDate. Treatment of Diabetic Neuropathy. Eva L. Feldman M.D, PhD, David K. McCulloch, M.D..
  • UpToDate. Subacute and Chronic Low Back Pain. Parmacologic and Noninterventional Treatment. Roger Chou, M.D..
  • Kroeling P, Gross A, Graham N, et al. Electrotherapy for neck pain. Cochrane Database Syst Rev. 2013;(8):CD004251.
  • Bril V, England J, Franklin GM et al. Evidence-based guideline: Treatment of painful diabetic neuropathy: report of the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation. Neurology 2011; 76(20):1758-65.
  • Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Transcutaneous electric nerve stimulation (TENS) or percutaneous electric nerve stimulation (PENS) in the treatment of chronic and postoperative pain. TEC Assessments 1996; Volume 11, Tab 21.

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Policy History: 

Date                                 Reason                              Action

October 2010                  Annual review                     Policy renewed
February 2011                 Interim review                     Policy revise

January 2012                   Annual review                     Policy renewed
January 2013                   Annual review                     Policy renewed
January 2014                   Annual review                     Renewed and new policy created

November 2014                Annual review                     Policy revised


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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.

*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.

 
Contact Information
New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:
  Wellmark Blue Cross and Blue Shield
  Medical Policy Analyst
  P.O. Box 9232
  Des Moines, IA 50306-9232
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