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    v1.0.28
    OpenPayerPolicy UpdatesDurable Medical Equipment (DME)Health Choice Arizona IFS Coverage | OpenPayer
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    CurrentHealth Choice ArizonaPolicy O875.10

    Interferential Current Stimulation

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    This policy governs coverage determinations for interferential current stimulation (IFS) as durable medical equipment and related services. Coverage depends on the member's benefit eligibility and the medical-necessity or experimental-investigational criteria described in the policy.

    Policy Summary
    PayerHealth Choice Arizona
    PolicyInterferential Current Stimulation
    Policy CodePolicy O875.10
    Change TypeNo material change
    Effective DateJan 3, 2023
    Last ReviewJan 3, 2023
    Next Review DateJan 1, 2024
    Key ActionWhen requesting an exception to the guideline, provide BCBSAZ complete medical rationale.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    3Medically necessary indications
    5Experimental or investigational criteria
    5

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    Listed billing codes
    4,000 Hz and 150 HzIFS current frequencies

    Coverage Criteria

    Medically necessary indications

    Interferential current stimulation is considered medically necessary for ANY of the following:

    ONE of

    • Chronic intractable localized pain: Symptomatic relief of chronic, intractable, localized pain.3 months or greater
    • Post-surgical localized pain: Management of post-surgical localized pain when oral or intravenous medications have failed to control pain or are contraindicated.
    • Post-traumatic acute localized pain: Management of post-traumatic, acute, localized pain.

    Experimental or investigational indications

    IFS for all other indications not previously listed, or when the medically necessary criteria are not met, is considered experimental or investigational when any ONE or more of the following criteria are met:

    ONE or more

    • Regulatory approval lacking: Lack of final approval from the appropriate governmental regulatory bodies, such as the Food and Drug Administration.
    • Insufficient scientific evidence to permit conclusions concerning the effect on health outcomes.
    • Insufficient net health outcome evidence: Insufficient evidence to support improvement of the net health outcome.
    • Insufficient comparative evidence: Insufficient evidence to support improvement of the net health outcome as much as, or more than, established alternatives.
    • Insufficient evidence outside investigation: Insufficient evidence to support improvement outside the investigational setting.

    Examples of indications considered experimental or investigational include labor and vaginal delivery pain relief, treatment of dementia, and treatment or prevention of muscle atrophy. Interferential current stimulation may also be considered experimental or investigational for other indications when applicable regulatory approval or supporting scientific, comparative, net-health-outcome, or non-investigational-setting evidence is lacking.

    Billing and Coding

    CPT CodesCPT
    97014
    97032
    HCPCS CodesHCPCS
    G0283
    S8130
    S8131
    Chronic Pain Duration
    Minimum duration3 months or greater
    Pain classificationChronic, intractable, localized pain
    Coverage contextSymptomatic relief of chronic pain is a medically necessary indication when the duration threshold is met.
    High-Frequency Current
    Current typeHigh-frequency alternating current
    Frequency4,000 Hz
    Circuit configuration

    Provider Documentation and Coverage Actions

    Documentation Required

    Complete Medical Rationale Required for Exceptions

    When requesting an exception to these guidelines, providers must submit BCBSAZ with a complete medical rationale supporting the exception.

    Denial Risk

    Coverage Denial Risk When Criteria Are Not Met

    Interferential current stimulation is medically necessary only for an approved indication and when at least one listed criterion applies. Requests for other indications, or requests that do not meet the medical-necessity criteria, are considered experimental or investigational when any one of the following conditions applies:

    • Chronic (3 months or greater), intractable, localized pain is not being treated for symptomatic relief.
    • Post-surgical localized pain is not being managed after oral or intravenous medications failed or were contraindicated.
    • Post-traumatic, acute, localized pain is not the indication.

    Background

    Interferential current stimulation (IFS) is an electrical stimulation therapy that uses paired electrodes from two independent circuits carrying high-frequency and medium-frequency alternating currents. The electrodes are placed on the skin around the affected area to deliver stimulation through the tissues, with less unwanted cutaneous-nerve stimulation than transcutaneous electrical stimulation. Treatment protocols may vary by frequency, pulse duration, treatment time, and electrode placement.

    Key Definition

    Interferential Current Stimulation (IFS)
    DefinitionA type of electrical stimulation using paired electrodes from two independent circuits carrying alternating currents.
    Electrode placementSuperficial electrodes are aligned on the skin around the affected area.
    High-frequency current4,000 Hz alternating current
    Medium-frequency current150 Hz alternating current

    IFS Medical Necessity

    IFS medical necessity

    Interferential current stimulation is considered medically necessary when ANY one of the following indications is present:

    ONE of

    • Chronic intractable localized pain: Symptomatic relief of chronic, intractable, localized pain.3 months or greater
    • Post-surgical localized pain: Management of post-surgical localized pain when oral or intravenous medications have failed to control pain or are contraindicated.
    • Post-traumatic acute localized pain: Management of post-traumatic, acute, localized pain.
    Policy Summary
    PayerHealth Choice Arizona
    PolicyInterferential Current Stimulation
    Policy CodePolicy O875.10
    Change TypeNo material change
    Effective DateJan 3, 2023
    Last ReviewJan 3, 2023
    Next Review DateJan 1, 2024
    Key ActionWhen requesting an exception to the guideline, provide BCBSAZ complete medical rationale.
    SourceLink
    On This Page
    Coverage CriteriaBilling and CodingProvider Documentation and Coverage ActionsBackgroundKey DefinitionIFS Medical Necessity
    One of two independent circuits used with paired electrodes
    Medium-Frequency Current
    Current typeMedium-frequency alternating current
    Frequency150 Hz
    Circuit configurationOne of two independent circuits used with paired electrodes
  1. The appropriate governmental regulatory body, such as the FDA, has not granted final approval.
  2. Scientific evidence is insufficient to determine the effect on health outcomes.
  3. Evidence is insufficient to support improvement of the net health outcome.
  4. Evidence is insufficient to support improvement of the net health outcome compared with established alternatives.
  5. Evidence is insufficient to support improvement outside the investigational setting.
    6. Denial Risk

    Experimental or Investigational Indications

    Interferential current stimulation for indications outside those meeting the medical-necessity criteria is considered experimental or investigational. Examples include:

    • Labor and vaginal delivery pain relief
    • Treatment of dementia
    • Treatment or prevention of muscle atrophy
    Documentation Required

    Verify Benefit Eligibility and Support Exceptions

    Coverage for interferential current stimulation and related services, procedures, medical devices, and drugs depends on the member's eligibility under the specific benefit plan. Providers requesting an exception must submit BCBSAZ a complete medical rationale; benefit eligibility and the submitted rationale are required considerations in determining coverage.