Anthem Blue Cross ConnecticutCommercial Clinical Policy

Anthem Blue Cross Connecticut DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices Form

Effective Date

12/28/2023

Last Reviewed

08/10/2023

Original Document

  Reference



This document addresses certain types of electrical stimulation devices. These include auricular electrostimulation, H-Wave stimulation, interferential stimulation therapy, microcurrent electrical nerve stimulation, pulsed electrical stimulation, percutaneous neuromodulation therapy, supraorbital transcutaneous neurostimulation, sympathetic therapies, cranial electrical stimulation and remote electrical neuromodulation. The devices differ in various ways including the type and intensity of electrical impulse and technique for delivering electrical stimulation.

Note: For further information on similar technologies, please see the following related documents:

  • CG-DME-03 Neuromuscular Stimulation in the Treatment of Muscle Atrophy
  • CG-DME-04 Electrical Nerve Stimulation, Transcutaneous, Percutaneous
  • DME.00022 Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)
  • SURG.00158 Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain

Note: For additional information concerning acupuncture services, please see the following document:

  • CG-ANC-03 Acupuncture

Position Statement

Investigational and Not Medically Necessary:

Note: For examples of devices, see Types of Devices Used for Treatment in the Background/Overview section.

Electrical stimulation using the following techniques is considered investigational and not medically necessary for all indications:

  1. Auricular electrostimulation
  2. Cranial electrical stimulation (CES)
  3. Electrical stimulation wound treatment device
  4. Electromagnetic wound treatment device
  5. H-Wave electrical stimulation devices
  6. Interferential therapy (IF)
  7. Microcurrent electrical nerve stimulation (MENS) devices
  8. Non-implantable percutaneous neuromodulation therapy
  9. Percutaneous electrical nerve field stimulation (PENFS)
  10. Pulsed electrical stimulation
  11. Pulsed electromagnetic field stimulation (PEMF)
  12. Remote electrical neuromodulation (REN)
  13. Supraorbital transcutaneous neurostimulation
  14. Sympathetic Therapy
  15. Transcutaneous electrical modulation pain reprocessing