Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT)
Policy #:MA05.064

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

Percutaneous electrical nerve stimulation and percutaneous neuromodulation therapy are considered covered for individuals, when used as a diagnostic procedure and performed by a professional provider or incident to a professional provider's service, to determine if pain is effectively controlled by percutaneous stimulation, therefore warranting implantation of an electrical nerve stimulator and electrodes.

Generally the professional provider should be able to determine whether the individual is likely to derive a significant therapeutic benefit from continuing use of an implanted nerve stimulator within a trial period of one month. Typical treatment regimens consist of 30- minute sessions, one to three times per week for 3 to 4 weeks.

Percutaneous electrical nerve stimulation and percutaneous neuromodulation therapy, when used as a treatment for pain, is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published literature.

PLACE OF SERVICE

Percutaneous electrical nerve stimulation and percutaneous neuromodulation therapy are performed in a professional provider’s office, clinic, or hospital outpatient department setting.

Percutaneous electrical nerve stimulation and percutaneous neuromodulation therapy do not meet the Company's definition of durable medical equipment (DME) because it is inappropriate for home use.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Policy Guidelines

This policy is consistent with Medicare’s coverage determination for percutaneous electrical nerve stimulation (PENS) and percutaneous neuromodulation therapy (PNT). The Company’s payment methodology may differ from Medicare.

Subject to the terms and conditions of the applicable Evidence of Coverage, percutaneous electrical nerve stimulation (PENS) and percutaneous neuromodulation therapy (PNT) are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

Description

Percutaneous electrical nerve stimulation (PENS) is a minimally invasive, non-surgical procedure in which needle-like electrodes are temporarily inserted (to a depth of one to four centimeters) into the deep tissues (muscles, ligaments, tendons) around or immediately adjacent to the nerve serving the painful area in order to electrically stimulate the peripheral nerve fibers. The intensity of the electrical stimulation is adjusted to produce the highest tolerable or comfortable electrical sensation without evidence of muscle contraction. A PENS unit consists of one or more electric signal generators, a battery, and a set of electrodes. Frequencies used during PENS include, low-frequency (2 to 4 Hz), intermediate-frequency (10 to 30 Hz), and high-frequency (75 to 200 Hz). Treatment regimens consist of 30- minute sessions, one to three times per week for 3 to 4 weeks.

PENS is generally reserved for individuals who fail to get pain relief from transcutaneous electrical nerve stimulation (TENS), due to physical barriers that inhibit the electrical stimulation (e.g., skin resistance, scar tissue, obesity). Contraindications to PENS are the same as those for electrical stimulation in general: avoid pregnant individuals, individuals who have carcinoma, and stimulation over the thorax in individuals with pacemakers. PENS is not the same as acupuncture with electrical stimulation (i.e., electroacupuncture). In electrical acupuncture, needles are inserted below the skin, but placement is based on specific theories regarding energy flow throughout the human body (i.e., meridians and acupoints). However, in PENS, the needles are placed not at acupoints, but along dermatomes, myotomes, and scleratomes to activate peripheral nerves. Thus, the location of stimulation using PENS is determined by proximity to the pain rather than the theories of energy flow that guide placement of stimulation for acupuncture.

Percutaneous neuromodulation therapy (PNT) is a variation of PENS in which fine filament electrode arrays are placed near the area that is causing pain. Some use the terms PENS and PNT interchangeably.
References

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD).160.7.1: Assessing Patient's Suitability for Electrical Nerve Stimulation Therapy. [CMS Web site]. 6/19/2006. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=63&ncdver=2&CoverageSelection=National&KeyWord=Electrical+Nerve+Stimulation&KeyWordLookUp=Title&KeyWordSearchType=And&list_type=ncd&bc=gAAAABAAAAAA&. Accessed February 8, 2019.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

THE FOLLOWING CODE REPRESENTS PERCUTANEOUS ELECTRICAL NERVE STIMULATION (PENS) AND PERCUTANEOUS NEUROMODULATION THERAPY (PNT):


64999



Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements






Policy History

MA05.064
03/13/2019The policy has been reviewed and reissued to communicate the Company’s continuing position on Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT).
03/14/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT).
03/29/2017The policy has been reviewed and reissued to communicate the Company’s continuing position on Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT).
03/30/2016The policy has been reviewed and reissued to communicate the Company’s continuing position on Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT).
6/24/2015The policy has been reviewed and reissued to communicate the Company’s continuing position on Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT).
01/01/2015This is a new policy.





Version Effective Date: 01/01/2015
Version Issued Date: 01/01/2015
Version Reissued Date: 03/13/2019