Medical Policy: 01.01.24
Original Effective Date: November 2000
Reviewed: November 2014
Revised: November 2014
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.
Pulsed electrical stimulation (PES) (also referred to as transcutaneous electrical joint stimulation) is the application of a signal specific electrical current (at low amplitude and low frequency) to joint tissue to relieve the signs and symptoms of osteoarthritis (OA) of the knee and rheumatoid arthritis (RA) of the hand.
The original Bio-1000 device was first approved for marketing in 2003. The signal was delivered via electrodes and gel and held on the leg with a wrap. The current system delivers the same patented signal but adds the benefit of the OActiveTM osteoarthritis knee brace to apply the device to the leg. The OActive knee brace reduces pain with activity via an unloading mechanism.
The original device is no longer available.
The BioniCare system is contraindicated in patients with demand-type pacemakers and may interfere with other electronic devices.
Pulsed electrical stimulation (PES) (also referred to as transcutaneous electrical joint stimulation) is considered not medically necessary for the treatment of osteoarthritis and all other indications because their effectiveness has not been established.
Based on peer reviewed literature there is insufficient evidence to indicate the effectiveness of pulsed electrical stimulation (PES) (also referred to as transcutaneous electrical joint stimulation) to improve health outcomes and therefore, is considered not medically necessary.
Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
- E0762 Transcutaneous electrical joint stimulation device system, includes all accessories
Wellmark's policy is based on:
- Farr j Mont m Farland D et al; Pulsed Electrical Stimulation in patients with osteoarthritis. Surg Tech Internatl 2006; 15: 227-33.
- American College of Rheumatology 2012 Recommendations for the Use of Nonpharmacologic and Pharmacologic Therapties in Osteoarthritis of the Hand, Hip and Knee. Marc C. Hochberg, Roy D. Altman, Karine Toupin April, Maria Benkhalti, Gordon Guyatt, Jessie McGowan, Tanveer Towheed, Vivian Welch, George Wells, and Peter Tugwell. Arthritis Care and Research, Vol. 64, No. 4, April 2012, pp 465-474. DOI 10.1002/acr.21596.
- American Academy of Orthopaedic Surgeons (AAOS) Treatment of Osteoarthritis of the Knee, Summary of Recommendations.
- ECRI Institute. Pulsed Electrical Stimulation for Knee Osteoarthritis. Published 5/19/2011.
- Agency for Healthcare Research and Quality (AHRQ). Physical Therapy Interventions for Knee Pain Secondary to Osteoarthritis.
- UpToDate. Nonpharamcologic Therapy for Osteoarthritis. Kenneth C. Kalunian, M.D..
- UpToDate. Nonpharmacologic and Preventative Therapies of Rheumatoid Arthritis. Peter H. Schur M.D., Allan Gibofsky, M.D..
Date Reason Action
October 2010 Annual review Policy renewed
February 2011 Interim review Policy revised
January 2012 Annual review Policy renewed
January 2013 Annual review Policy renewed
January 2014 Annual review Renewed & new policy created
November 2014 Annual review Policy revised
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.