CurrentHealth Choice ArizonaPolicy O313.16

Percutaneous Electrical Nerve Stimulation and Percutaneous Neuromodulation Therapy

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This policy governs coverage determinations for percutaneous electrical nerve stimulation (PENS) and percutaneous neuromodulation therapy (PNT) for chronic pain. Coverage depends on the member’s benefit plan, and the criteria determine whether these services are medically necessary or experimental/investigational.

Policy Summary

PayerHealth Choice Arizona

PolicyPercutaneous Electrical Nerve Stimulation and Percutaneous Neuromodulation Therapy

Policy CodePolicy O313.16

Change TypeNo material change

Effective Date09/19/2022

Last ReviewAug 16, 2022

Next Review Date3rd quarter 2023

Key ActionConfirm that the member has failed to obtain pain relief from TENS before considering PENS.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Experimental/investigational criteria

2FDA 510(k) clearances

5Chronic pain conditions

TENS failure

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CurrentHealth Choice ArizonaPolicy O313.16

Percutaneous Electrical Nerve Stimulation and Percutaneous Neuromodulation Therapy

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Sign up for health_choice_arizona Policy O313.16 alerts

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Policy Summary

PayerHealth Choice Arizona

PolicyPercutaneous Electrical Nerve Stimulation and Percutaneous Neuromodulation Therapy

Policy CodePolicy O313.16

Change TypeNo material change

Effective Date09/19/2022

Last ReviewAug 16, 2022

Next Review Date3rd quarter 2023

Key ActionConfirm that the member has failed to obtain pain relief from TENS before considering PENS.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Experimental/investigational criteria

2FDA 510(k) clearances

5Chronic pain conditions

TENS failure

Experimental or Investigational Determination

Percutaneous electrical neurostimulation (PENS) or percutaneous neuromodulation therapy (PNT) is considered experimental or investigational when ANY ONE or more of the following criteria are met:

ANY ONE or more of the following

Lack of final approval from the appropriate governmental regulatory bodies (e.g., Food and Drug Administration).
Insufficient scientific evidence to permit conclusions concerning the effect on health outcomes.
Insufficient evidence to support improvement outside the investigational setting.

Billing and Coding

CPTCPT

64999

HCPCSHCPCS

L8679
L8680

Provider Considerations

Step Therapy

Confirm prior TENS failure

Before considering PENS, confirm that the individual failed to obtain pain relief from transcutaneous electrical nerve stimulation (TENS). PENS is generally reserved for individuals who fail to get pain relief from TENS.

Denial Risk

Assess experimental or investigational status

PENS or PNT is considered experimental or investigational when any one or more of the listed conditions apply, creating a denial risk. Do not expect coverage when there is no final approval from the appropriate governmental regulatory bodies, insufficient scientific evidence to determine effects on health outcomes, or insufficient evidence of improvement outside the investigational setting.

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 evidence to support improvement outside the investigational setting.

Therapy Overview

Percutaneous electrical nerve stimulation (PENS) and percutaneous neuromodulation therapy (PNT) combine features of electroacupuncture and transcutaneous electrical nerve stimulation (TENS) to stimulate peripheral sensory nerves near a painful area. PENS uses needle electrodes placed around or immediately adjacent to the nerves serving the painful area. PNT is a variant of PENS that uses very fine needle-like or filament electrode arrays placed near the pain source in soft tissue.

These therapies have been evaluated for persistent chronic musculoskeletal or neuropathic pain, including low back pain, neck pain, diabetic neuropathy, chronic headache, and surface hyperalgesia. PENS differs from electrical acupuncture because electrode placement is determined by proximity to the pain rather than theories regarding energy flow. PENS is generally reserved for individuals who do not obtain pain relief from TENS.

Therapy Definitions

Percutaneous electrical nerve stimulation (PENS)

TermPercutaneous electrical nerve stimulation (PENS)

ElectrodesUses needle electrodes.

Purpose and placementStimulates peripheral sensory nerves near the painful area.

Percutaneous neuromodulation therapy (PNT)

TermPercutaneous neuromodulation therapy (PNT)

Electrode arraysUses very fine needle-like electrode arrays.

Purpose and placementArrays are placed near the painful area to stimulate peripheral sensory nerves in soft tissue.

Prior Treatment Requirements

Prior TENS Failure Before PENS

Before PENS is considered, the member must have failed to obtain pain relief from conservative electrical stimulation therapy:

ALL of the following

The individual has undergone transcutaneous electrical nerve stimulation (TENS).
TENS did not provide pain relief.
PENS is generally reserved for individuals who fail to get pain relief from TENS.

Prior Failure of Other Treatments

The chronic pain condition must have failed other treatments before PENS or PNT is evaluated:

The individual has a chronic pain condition for which other treatments have previously failed.

The policy states that these chronic pain conditions have typically failed other treatments before PENS or PNT is evaluated.

Not Covered Services

PENS or PNT is not covered when it is considered experimental or investigational. This determination applies when any one or more of the following conditions are present: the service lacks final approval from the appropriate governmental regulatory bodies, such as the Food and Drug Administration; scientific evidence is insufficient to permit conclusions about effects on health outcomes; or evidence is insufficient to support improvement outside the investigational setting.