Electrical Stimulators - Cigna

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845.0-845.19 Sprains and strains of ankle and foot 846.0-846.9 Sprains and strains of sacroiliac region 847.0-847.9 Sprains and strains of other and unspecified parts of back 848.0-848.9 Other ill-defined sprains and strains 959.01-959.9 Injury, other and unspecified 994.6 Motion sickness V11.3 Personal history of alcoholism V76.51 Special screening for malignant neoplasms, colon All other codes Experimental/Investigational/Unproven/Not Covered when used to report PrimaBella nerve stimulation therapy: HCPCS Description Codes E0765 FDA approved nerve stimulator, with replaceable batteries, for treatment of nausea and vomiting ICD-9-CM Diagnosis Codes 643.00- 643.93 Page 28 of 41 Description Excessive vomiting in pregnancy Miscellaneous Other <strong>Electrical</strong> Stimulation Devices Experimental/Investigational/Unproven/Not Covered: HCPCS Description Codes E0740 Incontinence treatment system, pelvic floor stimulator, monitor, sensor and/or trainer E0764 Functional neuromuscular stimulator, transcutaneous stimulation of muscles of ambulation with computer control, used for walking by spinal cord injured, entire system, after completion of training program E0770 Functional electrical stimulator, transcutaneous stimulation of nerve and/or muscle groups, any type, complete system, not otherwise specified. E1399 † Durable medical equipment, miscellaneous † Note: Not covered when used to report any electrical stimulator device indicated in this coverage policy as experimental, investigational or unproven. ICD-9-CM Diagnosis Codes Description All codes *Current Procedural Terminology (CPT ® ) © 2011 American Medical Association: Chicago, IL. References 1. Acumed. ETPS SM neuromechanical therapy. 2010. Accessed Jul 5, 2011. Available at URL address: http://www.acumedmedical.ca/
2. Agency for Healthcare Research and Quality (AHRQ). Evidence Report/Technology Assessment number 187. Treatment of overactive bladder in women. Aug 2009. Accessed Jul 5, 2011. Available at URL address: http://www.ahrq.gov/clinic/epcindex.htm#dietsup 3. Agency for Healthcare Research and Quality (AHRQ). Evidence Report/Technology Assessment number 161. Fecal and urinary incontinence in adults, prevention. Dec 2007. Accessed Jul 5, 2011. Available at URL address: http://www.ahrq.gov/clinic/epcquick.htm#Ptopics 4. Alaven Pharmaceutical. PrimaBella. 2009. Accessed July 5, 2011. Available at URL address: http://www.primabellarx.com/ 5. Alves-Guerreiro J, Noble J, Lowe A, Walsh D. The effect of three electrotherapeutic modalities upon peripheral nerve conduction and mechanical pain threshold. Clin Physiol. 2001;21(6):704-11. 6. American Association for Chronic Pain. Frequently asked questions. Aug 8, 2011. Accessed Jul 5, 2011. Available at URL address: http://www.theacpa.org/faqlisting.aspx 7. Ambrosini E, Ferrante S, Pedrocchi A, Ferrigno G, Molteni F. Cycling induced by electrical stimulation improves motor recovery in postacute hemiparetic patients: a randomized controlled trial. Stroke. 2011 Apr;42(4):1068-73. 8. Amer-Cuenca JJ, Goicoechea C, Girona-López A, Andreu-Plaza JL, Palao-Román R, Martínez-Santa G, Lisón JF. Pain relief by applying transcutaneous electrical nerve stimulation (TENS) during unsedated colonoscopy: a randomized double-blind placebo-controlled trial. Eur J Pain. 2011 Jan;15(1):29-35. 9. American Headache Society. US Headache Consortium guidelines. 2006. Accessed Jul 15, 2011. Available at URL address: https://www.americanheadachesociety.org/professionalresources/USHeadacheConsortiumGuidelines.a sp 10. American Society of Anesthesiologists Task Force on Chronic Pain Management; American Society of Regional Anesthesia and Pain Medicine. 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. Apr 11, 2011. Accessed Jul 5, 2011. Available at URL address: http://journals.lww.com/anesthesiology/Fulltext/2010/04000/Practice_Guidelines_for_Chronic_Pain_Ma nagement_.13.aspx 11. Arena R, Pinkstaff S, Wheeler E, Peberdy MA, Guazzi M, Myers J. Neuromuscular electrical stimulation and inspiratory muscle training as potential adjunctive rehabilitation options for patients with heart failure. J Cardiopulm Rehabil Prev. 2010 Jul-Aug;30(4):209-23. 12. Barrett CL, Mann GE, Taylor PN, Strike P. A randomized trial to investigate the effects of functional electrical stimulation and therapeutic exercise on walking performance for people with multiple sclerosis. Mult Scler. 2009 Apr;15(4):493-504. 13. Bax L, Staes F, Verhagen A. Does neuromuscular electrical stimulation strengthen the quadriceps femoris? A systematic review of randomised controlled trials. Sports Med. 2005;35(3):191-212. 14. Bioness, Inc. NESS L300 Foot Drop System. 2010. Accessed Jul 5, 2011. Available at URL address: http://www.bioness.com/Healthcare_Professionals/How_L300_Works.php 15. Bjordal JM, Johnson MI, Lopes-Martins RAB, Bogen B, Chow R, Ljunggren AE. Short-term efficacy of physical interventions in osteoarthritic knee pain. A systematic review and meta- analysis of randomised placebo-controlled trials. BMC Musculoskelet Disord. 2007 Jun 22;8(1):51. Page 29 of 41
Page 1 and 2: Cigna Medical Coverage Policy Subje
Page 3 and 4: • microcurrent electrical nerve s
Page 5 and 6: ongoing assessment and management a
Page 7 and 8: Neck Pain: Following a systematic r
Page 9 and 10: of patients with chronic pain who h
Page 11 and 12: suppress spasticity. FES is a high-
Page 13 and 14: nerve electrical stimulation (OG) (
Page 15 and 16: terms of improving gait, but the ef
Page 17 and 18: standardized protocol for IFT, and
Page 19 and 20: velocity, which was sustained at si
Page 21 and 22: adverse events included ankle bruis
Page 23 and 24: Rhodes Index of Nausea, Vomiting an
Page 25 and 26: Codes 337.20- 337.29 Reflex sympath
Page 27: 496 Chronic airway obstruction, not
Page 31 and 32: 29. Chou R, Loeser JD, Owens DK, Ro
Page 33 and 34: 59. Guido EH. Effects of sympatheti
Page 35 and 36: 90. Laufer Y, Ring H, Sprecher E, H
Page 37 and 38: 121. Proctor M, Farquhar C, Stones
Page 39 and 40: 150. U.S. Food and Drug Administrat
Page 41: Policy History Pre-Merger Last Revi

Electrical Stimulators - Cigna

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