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Medical Policy: 07.01.08
Original Effective Date: June 1995
Reviewed: January 2012
Revised:
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:
Electric stimulation has been investigated as a treatment for idiopathic scoliosis to reverse or halt spinal curvature. It may be accomplished by:
- Surface electrical stimulation of the lateral spine or
- Deep muscle stimulation to the paraspinal musculature following implantation of electrodes into the paraspinal muscles with receiver placed beneath the skin.
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Prior Approval:
Not applicable
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Policy:
Electrical stimulation for scoliosis is considered investigational because the peer-reviewed literature does not support that it is as effective as brace treatment.
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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.
- E0744 for the neuromuscular stimulator for scoliosis.
- 64550 for application of surface (transcutaneous) neurostimulator.
- 64580 for incision for implantation of neurostimulator electrodes; neuromuscular.
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Selected References:
- Bertrand SL, et al. Electrical stimulation for idiopathic scoliosis. Clinical Orthopedic and Related Research 1992 March; (276):176-181.
- Nachemson AL, Peterson LE, Effectiveness of treatment with a brace in girls who have adolescent idiopathic scoliosis. A prospective, controlled study based on data from the Brace Study of the Scoliosis Research Society. J Bone joint Surg Am. 1995 Jun;77(6):815-22.
- Rowe DE, Bernstein SM, et al. A meta-analysis of the efficacy of non-operative treatments for idiopathic scoliosis. J Bone Joint Surg Am. 1998 Jun;80(6):923-5.
- Bowen JR, Keeler KA, Pelegie S. Adolescent idiopathic scoliosis managed by a nighttime bending brace. Orthopedics. 2001 Oct;24(10):967-70.
- ECRI. Uses of Therapeutic Electrical Stimulation. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2006 October 25. 7 p. (ECRI Hotline Response). Also available: http://www.ecri.org.
- Peterson LE; Machemson AL. Prediction of Progression of the curve in girls who have adolescent idiopathic scolosis of moderate severity. Logistic regression analysis based on data from The Brace Study of the Scoliosis Research Society. J Bone Surg Am. 1995 June; 77(6):823-7.
- Haefeli M, Elfering A, Kilian R, Min K, Boos N. Nonoperative treatment for adolescent idiopathic scoliosis: a 10- to 60-year follow-up with special reference to health-related quality of life. Spine 2006 Feb 1;31(3):355-66; discussion 367.
- Lenssinck ML, Frijlink AC, Berger MY, Bierman-Zeinstra SM, Verkerk K, Verhagen AP. Effect of bracing and other conservative interventions in the treatment of idiopathic scoliosis in adolescents: a systematic review of clinical trials. Phys Ther. 2005 Dec;85(12):1329-39.
- Shaughnessy WJ. Advances in Scoliosis Brace Treatment for Adolescent Idiopathic Scoliosis. Orthop Clin North Am. 2007 Oct;38(4):469-75.
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Policy History:
Date Reason Action
January 2011 Annual review Policy renewed
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.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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