CurrentNeighborhood Health Plan of Rhode IslandPolicy 077

Percutaneous Electrical Nerve Field Stimulation (IB-STIM) for Functional Abdominal Pain

Medical necessity and coverage criteria for use of the IB-STIM percutaneous electrical nerve field stimulation system to treat pediatric functional abdominal pain/functional gastrointestinal disorders for Neighborhood Health Plan of Rhode Island members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPercutaneous Electrical Nerve Field Stimulation (IB-STIM) for Functional Abdominal Pain

Policy CodePolicy 077

Change TypeNo material change

Effective DateDec 11, 2024

Next Review DateDec 11, 2024

Key ActionObtain prior authorization and submit documentation showing organic disease has been excluded and required prior therapies have failed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

11-18age range for covered use

>=9 mominimum symptom duration required

3 categoriesmedication therapy requirement

0720Tbilling code listed

pacemaker/hemophilia/psoriasisexplicit exclusions

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Coverage Criteria

Medical Necessity Criteria

Covered when ALL of the following are met:

IB-STIM medical necessity criteria: Member is 11-18 years of age AND member has a ROME IV defined functional gastrointestinal disorder (functional abdominal pain, functional abdominal pain syndrome, irritable bowel syndrome, functional dyspepsia, or abdominal migraine) AND organic disease has been excluded with documentation submitted AND symptoms present for at least 9 months AND member has trialed and failed diet modification AND there has been trial and failure of at least one medication in each of the three categories: (1) acid suppression (H2 blockers or proton pump inhibitors), (2) antispasmodics or motility medications (examples: hyoscyamine, dicyclomine, erythromycin, linaclotide, prucalopride), and (3) neuromodulators (examples: amitriptyline, nortriptyline, gabapentin, periactin, aprepitant).age 11-18; duration >=9 months

All elements must be met for coverage

Coverage for the IB‑STIM percutaneous electrical nerve field stimulation system is not available for members with any of the following conditions: history of a cardiac pacemaker, diagnosis of hemophilia, or diagnosis of psoriasis vulgaris. Requests for IB‑STIM in members with these conditions will be denied.

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required — providers must use Neighborhood Health Plan of Rhode Island's prior authorization process and forms available on the provider website. Access forms at www.nhpri.org: select Providers > Provider Resources > Forms > 'Click here for a list of prior authorization request forms'. For assistance, call 1-800-963-1001 (phone messaging system available during and outside business hours). Refer to the Authorization Quick Reference Guide for coding details.

Step Therapy

Required Prior Therapies

Required prior therapies: The member must have trialed and failed diet modification. In addition, there must be trial and failure of at least one medication from each of the following three medication categories: 1) Acid suppression (H2 blockers or proton pump inhibitors), 2) Antispasmodics or motility agents (e.g., hyoscyamine, dicyclomine, erythromycin, linaclotide, prucalopride), and 3) Neuromodulators (e.g., amitriptyline, nortriptyline, gabapentin, periactin, aprepitant).

Documentation Required

Coding

Covered CodesCPTCovered

0720T

Covered Code listed in policy

Definitions

ROME IV-defined functional gastrointestinal disorder

DefinitionFunctional gastrointestinal disorders per ROME IV include functional abdominal pain, functional abdominal pain syndrome, irritable bowel syndrome, functional dyspepsia, and abdominal migraine.

Age range referenced in ROME IV criteria for this policyApplies to members 11-18 years of age when used with IB-STIM per policy coverage criteria.

Clinical contextThese disorders are functional (no identified organic cause) and in this policy require documentation that organic disease has been excluded prior to coverage.

Mechanism relevancePENFS (IB-STIM) is an auricular neurostimulation technique that targets cranial nerve branches to modulate central pain pathways and visceral hypersensitivity in pediatric functional abdominal pain, supporting its use in ROME IV disorders.

Background

Percutaneous electrical nerve field stimulation (PENFS), delivered via the IB‑STIM system, is an auricular neurostimulation technique that applies low‑level electrical stimulation to nerves in the external ear with the intent of modulating central pain pathways and reducing visceral hypersensitivity. The device (marketed as IB‑STIM/NeuroStim) is FDA‑cleared and has been studied in pediatric populations with functional abdominal pain and irritable bowel syndrome, where the neuromodulation of afferent ear nerves is proposed to alter central processing of abdominal pain.