Electrical nerve stimulation is the use of electric current produced by a device to stimulate the nerves for therapeutic purposes.
Electrical nerve stimulation, (Transcutaneous electrical nerve stimulation (TENS) and Percutaneous electrical nerve stimulation) (PENS) may be considered medically necessary when used for the treatment of acute or chronic pain and as a means of assessing the need for continued treatment with an implanted electrical nerve stimulator.
Electrical nerve stimulation for pain control may be considered medically necessary when the following criteria have been met:
The use of PENS and TENS 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.
64999 |
A4595 |
E0720 |
E0730 |
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Supplies for electrical stimulation device may be considered medically necessary when annual documentation is noted in the individual's medical record.
Normal utilization with a covered electrical stimulation device is:
Procedure code A4595 is allowed 12 every one (1) floating month.
Quantity of supplies that exceed the frequency guidelines listed on this policy are considered not medically necessary.
A4595 |
E0720 |
E0730 |
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Phrenic Nerve Stimulator
The implantation of a United States Food and Drug Administration (U.S. FDA) approved phrenic nerve stimulator may be considered medically necessary:
64575 |
64580 |
64585 |
64590 |
64595 |
95970 |
95971 |
L8678 |
L8680 |
L8682 |
L8683 |
L8685 |
L8686 |
L8687 |
L8688 |
L8689 |
L8696 |
0424T |
0425T |
0426T |
0427T |
0428T |
0429T |
0430T |
0431T |
0432T |
0433T |
0434T |
0435T |
0436T |
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Vagus Nerve Stimulator
The implantation of a vagus (vagal) nerve stimulator for seizure control may be considered medically necessary only when used as a last resort for individuals with epilepsy (aged four (4) years and older) with partial onset seizures who have not undergone a bilateral or left cervical vagotomy.
A U.S. FDA approved vagus nerve stimulator for the management of epilepsy with partial onset seizures may be considered medically necessary for individuals when seizures cannot be controlled by any other method such as:
Vagus (vagal) nerve stimulation not meeting the criteria as indicated in this policy is considered not medically necessary.
61885 |
61886 |
64553 |
64568 |
64569 |
64570 |
95970 |
95976 |
95977 |
E1399 |
L8678 |
L8679 |
L8680 |
L8681 |
L8682 |
L8683 |
L8685 |
L8686 |
L8687 |
L8688 |
L8689 |
L8695 |
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Non-Implantable Vagus Nerve Stimulator
U.S. FDA approved non-implantable vagus nerve stimulation devices (i.e. gammaCore) may be considered medically necessary for the abortive treatment of migraine or cluster headache under ALL of the following circumstances:
In order to maintain coverage for gammaCore, the following efficacy must be documented:
· Reduction of pain from moderate or severe to mild or pain free within 60 minutes, without the use of rescue medicine, for at least 50% of attacks.
U.S. FDA approved non-implantable vagus nerve stimulation devices (i.e., gammaCore) may be considered medically necessary for the preventive treatment of migraine headache or for the acute treatment of pain associated with migraine headache under ALL of the following circumstances:
In order to maintain coverage for gammaCore, the following efficacy must be documented:
Non-implantable stimulation devices not meeting the criteria as indicated in this policy are 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.
K1020 |
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Percutaneous Nerve Field Stimulator
The use of a Percutaneous nerve field stimulator in opioid withdrawal treatment 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.
64999 |
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Percutaneous Neuromodulation Therapy
The use of percutaneous neuromodulation therapy 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.
64999 |
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Percutaneous or Open Implantation of Neuromuscular Neurostimulator
The percutaneous or open (via incision) implantation of neuromuscular neurostimulator electrodes for chronic pain relief 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.
64580 |
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Occipital Nerve Stimulation (ONS)
ONS 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.
61885 |
61886 |
64553 |
64568 |
64569 |
64570 |
64999 |
L8678 |
L8680 |
L8681 |
L8682 |
L8683 |
L8685 |
L8686 |
L8687 |
L8688 |
L8689 |
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Remote Electrical Neuromodulation
The use of a Remote Electrical Neuromodulation (REN) device (i.e. Nerivio) 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.
E1399 |
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Percutaneous Electrical Nerve Field Stimulator
The use of a Percutaneous Electrical Nerve Field Stimulator (PENFS) device 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.
64999 |
E1399 |
0720T |
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External Trigeminal Nerve Stimulation System
An external trigeminal nerve stimulation (eTNS) system 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.
K1016 |
K1017 |
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External Upper Limb Tremor Stimulator
An external upper limb tremor stimulator 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.
K1018 |
K1019 |
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Transcutaneous Electrical Modulation Pain Reprocessing Therapy
Transcutaneous electrical modulation pain reprocessing therapy (TEMPR) (i.e., scrambler therapy) 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.
0278T |
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Replacement batteries are not eligible for payment and therefore non-covered.
A4630 |
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C1767 |
C1778 |
C1816 |
C1820 |
C1822 |
C1823 |
C1826 |
C1883 |
C1897 |
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Refer to Medical Policy S-131, Sacral Nerve Neuromodulation/Stimulation, for additional information.
Refer to Medical Policy S-155, Gastric Electrical Stimulation, Gastric Pacing, for additional information.
Refer to Medical Policy Y-16, Chronic Wound Management, for additional information.
Refer to Medical Policy E-40, Functional Neuromuscular Electrical Stimulation (NMES), for additional information.
Refer to Medical Policy Z-8, Diagnosis and Treatment of Obstructive Sleep Apnea for Adults, for additional information.
Refer to Medical Policy Z-100, Deep Brain Stimulation, for additional information.
Refer to Medical Policy S-51, Responsive Neurostimulation for the Treatment of Refractory Partial Epilepsy, for additional information.
Refer to Medical Policy V-23, Temporomandibular Joint (TMJ) Dysfunction, for additional information.
Refer to Medical Policy Z-64, Diagnosis and Treatment of Obstructive Sleep Apnea in Pediatric Individuals, for additional information.
Covered Diagnosis Codes for Vagus Nerve Stimulation (61885, 61886, 64553, 64568, 64569, and 64570)
G40.001 |
G40.009 |
G40.011 |
G40.019 |
G40.101 |
G40.109 |
G40.111 |
G40.119 |
G40.201 |
G40.209 |
G40.211 |
G40.219 |
G40.C01 |
G40.C09 |
G40.C11 |
G40.C19 |
Z45.42 |
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Covered Diagnosis Codes for Non-implantable Vagus Nerve Stimulation (K1020) for individuals aged 18 or older
G43.001 |
G43.009 |
G43.011 |
G43.019 |
G43.101 |
G43.109 |
G43.111 |
G43.119 |
G44.011 |
G44.019 |
G44.021 |
G44.029 |
G44.001 |
G44.009 |
Covered Diagnosis Codes for Non-implantable Vagus Nerve Stimulation (K1020) for Individuals aged twelve 12-17
G43.001 |
G43.009 |
G43.011 |
G43.019 |
G43.101 |
G43.109 |
G43.111 |
G43.119 |
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Covered Diagnosis Codes for Phrenic Nerve Stimulation (0424T, 0425T, 0426T, 0427T, 0428T, 0429T, 0430T, 0431T, 0432T, 0433T, 0434T, 0435T, and 0436T)
G47.31 |
G47.34 |
G47.35 |
G47.36 |
G47.37 |
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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you need these services, contact the Civil Rights Coordinator.
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association. Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York]. All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.