CurrentKaiser PermanentePolicy N/A

Clinical Review Criteria Bioimpedance Spectroscopy

Defines Kaiser Permanente Washington coverage and medical necessity criteria for bioimpedance spectroscopy (BIS)/bioelectrical impedance analysis used to assess lymphedema, and describes documentation needed when requesting the service. Applies to Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc.

Policy Summary

PayerKaiser Permanente

PolicyClinical Review Criteria Bioimpedance Spectroscopy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateMay 5, 2026

Key ActionWhen requesting this service, send the last 6 months of clinical notes from the requesting provider to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not medically necessaryCoverage stance for BIS/BIA

0358T, 93702Codes not covered

A-0667MCG guideline

Last 6 months notesDocumentation requested

Coverage Determination

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Not Medically Necessary

Covered when ALL of the following are met:

Main stance: Bioimpedance spectroscopy/bioelectrical impedance analysis for lymphedema assessment is considered not medically necessary per Kaiser Permanente criteria and MCG guidance for non-Medicare members; the Medical Technology Assessment Committee (MTAC) concluded bioimpedance lymph analysis does not meet Kaiser Permanente Medical Technology Assessment Criteria.

See coding list for specific CPT/HCPCS codes considered not medically necessary (see coding section).

MCG guideline A-0667 has been adopted for medical necessity determinations for non‑Medicare members and, per that guidance, this service is not covered. The Medical Technology Assessment Committee (MTAC) review similarly concluded that available evidence does not establish sufficient accuracy, reliability, or impact on patient management to support bioimpedance lymph analysis as a covered diagnostic standard.

Bioimpedance spectroscopy / bioelectrical impedance analysis using CPT/HCPCS codes 0358T and 93702 is considered not medically necessary for lymphedema assessment.

BIS purpose and lack of covered indications

Purpose and coverage note:

Purpose: Bioimpedance spectroscopy (BIS) / bioelectrical impedance analysis (BIA) is a noninvasive procedure that uses skin electrodes and low-level alternating current to measure electrical impedance as an indirect estimate of extracellular fluid; it has been proposed to detect subclinical increases in extracellular fluid prior to changes in limb volume.

Coverage note: Despite its intended purpose to detect extracellular fluid changes, BIS/BIA for lymphedema assessment is listed as considered not medically necessary and there are no covered indications for this service per Kaiser Permanente policy; specific CPT/HCPCS codes identified as not medically necessary are 0358T and 93702.

To verify authorization requirements by plan type, use the Pre-authorization Code Check.

Provider Actions and Authorization

Prior Authorization

Prior Authorization / Pre-approval

Verify whether prior authorization / pre-approval is required for the requested service by plan type before submitting. Use the payer's Pre-authorization Code Check to confirm authorization requirements for specific CPT/HCPCS codes.

Use Pre-authorization Code Check to confirm requirements by plan type
Contact Kaiser Permanente Clinical Review staff at 1-800-289-1363 to request the specific MCG criteria used in a utilization decision (if applicable)

Documentation Required

Required Documentation

Submit supporting clinical documentation to demonstrate medical necessity for the requested service.

Include the last 6 months of clinical notes from the requesting provider

Denial Risk

Denial Triggers — Not Medically Necessary Codes

Use of the following CPT/HCPCS codes for bioimpedance spectroscopy (BIS) / bioelectrical impedance analysis (BIA) for lymphedema assessment is considered not medically necessary and may be denied.

0358T — Bioelectrical impedance analysis whole body composition assessment, with interpretation and report
93702 — Bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema assessment(s)
Codes listed may not be all-inclusive; deleted or out-of-effect codes may not be covered

Note

Provider-Facing Highlight

For Medicare members, in the absence of an active NCD or LCD, Kaiser Permanente applies its own Clinical Review Criteria (Bioimpedance Spectroscopy) for medical necessity determinations. For non-Medicare members, Kaiser Permanente uses the MCG guideline (A-0667) for determinations; the service is not covered per MCG guidance.

Medicare: Kaiser Permanente Clinical Review Criteria — Bioimpedance Spectroscopy
Non-Medicare: MCG A-0667 (service not covered per MCG)

How to Order / Documentation Needed

Step Therapy

Ordering requirement: provide last 6 months of clinical notes

Providers requesting this service must submit the last 6 months of clinical notes from the requesting provider when ordering the test to support medical necessity.

Include the requesting provider's clinical notes for the prior 6 months with the authorization or claim submission.

Clinical Background

Lymphedema is a chronic, progressive disorder characterized by interstitial accumulation of protein‑rich fluid leading to swelling, inflammation, and fibrosis. Secondary lymphedema most commonly occurs after malignancy treatment (for example, breast cancer surgery or radiation). Common methods to quantify limb volume include limb circumference measurements, water displacement, and perometry; bioimpedance techniques estimate extracellular fluid by measuring tissue electrical impedance and have been proposed to detect subclinical fluid changes.

Definitions

Definition — Bioimpedance Spectroscopy / Bioelectrical Impedance Analysis

Test typeBioimpedance Spectroscopy (BIS) / Bioelectrical Impedance Analysis (BIA)

MethodNoninvasive procedure using skin electrodes to pass a low-level alternating current through the limb and measure electrical impedance.

What it measuresImpedance to current flow; changes in impedance are inversely proportional to extracellular fluid volume in the extremity.

Frequency dependenceAt low frequencies current passes only through extracellular fluid; at high frequencies current passes through cell membranes and both extra- and intracellular fluids—impedance varies with frequency.

Clinical intentProposed to differentiate extracellular fluid from total limb volume and to detect early/subclinical increases in extracellular fluid for lymphedema assessment.