CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Percutaneous Electrical Nerve Stimulation (PENS) / Percutaneous Neuromodulation Therapy (PNT) Coverage Policy

Policy governing coverage of percutaneous electrical nerve stimulation (PENS) and percutaneous neuromodulation therapy (PNT) for chronic pain conditions for Blue Cross & Blue Shield of Rhode Island members.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPercutaneous Electrical Nerve Stimulation (PENS) / Percutaneous Neuromodulation Therapy (PNT) Coverage Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 2, 2018

Next Review DateN/A

Key ActionFor Commercial products, do not bill PENS/PNT as covered — these are considered not medically necessary; for Medicare Advantage, perform only when performed by a physician or incident to a physician's service and follow CMS guidance.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2018-10-02Effective date

Not applicablePrior authorization

Unlisted 64999Coding

Not medically necessaryCommercial stance

Follows CMS

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Coverage Determinations

Coverage by product

Policy coverage differs by product:

Medicare Advantage coverage: PENS/PNT is considered medically necessary for treatment of chronic conditions when symptoms are effectively controlled by percutaneous stimulation and implantation of electrodes is warranted; procedure must be performed in a physician's office, clinic, or hospital outpatient department and by a physician or incident to a physician's service.

Medicare Advantage policies may differ from commercial.

Commercial coverage: PENS/PNT for chronic conditions is considered not medically necessary because the evidence is insufficient to determine the effects of the technology on health outcomes.

Claims for Commercial products may be denied on this basis.

For Commercial products, percutaneous electrical neurostimulation (PENS) and percutaneous neuromodulation therapy (PNT) are considered not medically necessary. The evidence is insufficient to determine the effects of these technologies on health outcomes for treatment of chronic conditions, and therefore coverage is not supported under Commercial plans.

Services determined to be not medically necessary or to be non-covered benefits are subject to non-payment and billing restrictions. Providers may not bill members for such services unless the member has been informed in advance and has agreed to assume financial responsibility for the service.

This policy reiterates that percutaneous electrical neurostimulation (PENS) and percutaneous neuromodulation therapy (PNT) for treatment of chronic conditions are not medically necessary for members covered under Commercial products due to insufficient evidence of benefit.

When a service is determined to be not medically necessary, claims may be denied and the service is not eligible for reimbursement under the member's plan. Providers should not charge the member for services deemed not medically necessary unless the member was informed ahead of time and explicitly agreed to pay out of pocket.

Coding Guidance

Coding guidanceCPT

64999

Unlisted procedure, nervous system specific

Provider Requirements and Actions

Prior Authorization

Prior authorization is not applicable for this policy.

Denial Risk

Coverage and Billing Risk

For Commercial products, PENS/PNT is considered not medically necessary; claims for these services may be denied. Document conservative treatments tried and failure of TENS when applicable. For Medicare Advantage, PENS is covered only when performed by a physician or incident to a physician's service in a physician's office, clinic, or hospital outpatient department.

Commercial: PENS/PNT considered not medically necessary — potential denial risk
Medicare Advantage: Covered only when performed by physician or incident to physician service in office/clinic/hospital outpatient
Document prior conservative treatments and failure of TENS before PENS

Background and Scope

Percutaneous electrical nerve stimulation (PENS) and percutaneous neuromodulation therapy (PNT) combine features of electroacupuncture and transcutaneous electrical nerve stimulation (TENS). These techniques use percutaneous needle electrodes or very fine filament electrode arrays placed adjacent to peripheral sensory nerves in the painful region to deliver electrical stimulation with the intent of modulating pain signals.

Definitions

PENS — definition and brief description

TermPercutaneous electrical nerve stimulation (PENS)

DefinitionNeedle electrodes inserted around or immediately adjacent to the peripheral nerves serving the painful area to provide electrical stimulation.

Typical useUsed to treat chronic musculoskeletal or neuropathic pain, generally reserved for patients who fail to obtain relief from transcutaneous electrical nerve stimulation (TENS).

PNT — definition and brief description

TermPercutaneous neuromodulation therapy (PNT)

DefinitionVariant of PENS that uses very fine filament (needle-like) electrode arrays placed near the painful area to stimulate peripheral sensory nerves.

Conservative Therapy Prerequisites

Failure of TENS (when applicable) before PENS

Covered when prior conservative therapy requirements are met:

Primary requirement: Documented failure of transcutaneous electrical nerve stimulation (TENS) to provide adequate pain relief when TENS is applicable to the pain condition.

PENS is generally reserved for patients who fail to get relief from TENS.

Setting and performer for subsequent PENS: If symptoms are effectively controlled by percutaneous stimulation and implantation of electrodes is warranted, PENS/PNT must be performed in a physician's office, clinic, or hospital outpatient department and by a physician or incident to a physician's service (Medicare Advantage).

Additional conservative treatment criteria / related nodes

Additional conservative treatment and documentation expectations:

Frequency and Quantity Limits

PENS/PNT — frequency limits

Frequency/LimitNo specific numeric visit or session frequency limits specified in this policy for PENS/PNT.

Service setting notePENS is performed in physician office, clinic, or hospital outpatient department for Medicare Advantage when medically indicated.

Coding implicationThere is no specific CPT code for PENS/PNT; use unlisted procedure code 64999 as coding guidance.

percutaneous electrical nerve stimulation / neuromodulation — frequency/limit entries

ProcedurePercutaneous electrical nerve stimulation / neuromodulation (general)

Frequency/Limit detailsPolicy does not define per-procedure or per-period frequency limits for percutaneous electrical nerve stimulation / neuromodulation.

Imaging and Diagnostic Requirements

Note

No imaging requirement specified for PENS/PNT

No specific imaging requirements are stated for PENS/PNT in the policy.

References list guidelines and trials but do not mandate imaging prior to PENS/PNT.

Note

Imaging: none required

The policy indicates 'no' explicit imaging requirements for PENS/PNT in the referenced sections.

Explicit Non-Covered Services

Commercial coverage: PENS and PNT for chronic pain conditions are not covered (considered not medically necessary) because current evidence is insufficient to establish effectiveness. Providers and billing staff should follow the policy guidance that claims for these services may be denied and members should not be billed unless they provided prior informed consent to pay privately.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPercutaneous Electrical Nerve Stimulation (PENS) / Percutaneous Neuromodulation Therapy (PNT) Coverage Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 2, 2018

Next Review DateN/A

SourceLink

On This Page

Step Therapy

Step Therapy / Conservative Sequencing

No step therapy program is specified in this policy. However, clinical guidance indicates PENS is generally reserved for patients who have failed transcutaneous electrical nerve stimulation (TENS); document prior conservative treatments and failure of TENS.

No formal step therapy requirements listed in policy
Clinical sequencing: trial of conservative measures including TENS recommended prior to PENS

Documentation Required

Benefits and Eligibility / Member Financial Responsibility

For member-specific benefits and eligibility, contact the provider call center. Benefits are determined by the member's subscriber agreement or employer agreement. If services are non-covered or not medically necessary, providers may not bill members unless the member has been informed and agreed in advance to pay.

Verify member eligibility and benefits via provider call center
Do not bill members for non-covered/not medically necessary services unless prior written/voiced agreement exists

NotesSometimes the terms PENS and PNT are used interchangeably; PNT is proposed to inhibit transmission by creating an electrical field that hyperpolarizes C fibers.

Conservative care documentation: Prior conservative treatments (e.g., noninvasive therapies recommended in clinical practice guidelines for low back pain or neuropathic pain) should be documented in the medical record.

References include guidelines (ACP, AAN/AAPM&R, NICE) that emphasize conservative management prior to invasive procedures.

Guideline context: Consideration of guideline-recommended conservative therapies (such as those in AAN/AAPM&R or ACP low back pain guidance) is expected when determining appropriateness of PENS/PNT.

No specific durations or step counts are specified in this policy segment.

ReferencesGuidance and evidence cited (NICE, AAN/AAPM&R, ACP, CMS) but no frequency thresholds provided in reference list.