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    OpenPayerPolicy UpdatesGastroenterologyPremera Nerve Stimulation Update | OpenPayer
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    ModifiedPremera Blue Cross of WashingtonPolicy 2.01.106

    Percutaneous Electrical Nerve Field Stimulation for Disorders of Gut-Brain Interaction

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    Coverage of percutaneous electrical nerve field stimulation for abdominal pain associated with disorders of gut-brain interaction, including irritable bowel syndrome and functional dyspepsia. The service is considered investigational.

    Policy Summary
    PayerPremera Blue Cross of Washington
    PolicyPercutaneous Electrical Nerve Field Stimulation for Disorders of Gut-Brain Interaction
    Policy CodePolicy 2.01.106
    Change TypeModified
    Effective DateNovember 6, 2026
    Last ReviewAug 1, 2026
    Next Review DateN/A
    Key ActionTreat requests for percutaneous electrical nerve field stimulation for abdominal pain-related disorders of gut-brain interaction as investigational and subject to denial.
    SourceLink
    POLICY UPDATE CHANGES

    The investigational policy statement was expanded from percutaneous electrical nerve field stimulation for irritable bowel syndrome to abdominal pain-related disorders of gut-brain interaction, including irritable bowel syndrome and functional dyspepsia.

    CPT code 64567 was added as the replacement code for CPT code 0720T.

    CPT code 0720T was removed from the policy coding table.

    InvestigationalCoverage status
    2CPT codes listed
    8+

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Minimum FDA-cleared age
    120 hours/week for 4 weeksFDA treatment schedule

    Coverage Criteria

    Percutaneous Electrical Nerve Field Stimulation

    The service is considered investigational.

    Investigational service: Percutaneous electrical nerve field stimulation for abdominal pain in individuals with disorders of gut-brain interaction, including but not limited to irritable bowel syndrome and functional dyspepsia, is considered investigational.

    Examples include IB Stim, First Relief v1, and TEA Device.

    Percutaneous electrical nerve field stimulation for abdominal pain-related disorders of gut-brain interaction, including irritable bowel syndrome and functional dyspepsia, is identified as investigational and is not covered under this policy.

    Coding Information

    Investigational CPT CodesCPTExperimental
    64567Percutaneous electrical nerve field stimulation, cranial nerves, without implantation (new code effective 01/01/26).
    0720TPercutaneous electrical nerve field stimulation, cranial nerves, without implantation (code termed effective 01/01/26)
    Current CPT code referenced in policy historyCPT
    64567New CPT code added; replaces 0720T.
    Removed CPT codeCPTNot Covered
    0720TCPT code removed from the policy coding table and replaced by 64567.
    FDA product codeHCPCS
    QHHFDA product code.

    Provider Guidance

    Denial Risk

    Investigational service: coverage may be denied

    Percutaneous electrical nerve field stimulation for abdominal pain in individuals with disorders of gut-brain interaction, including but not limited to irritable bowel syndrome and functional dyspepsia, is considered investigational and is subject to denial under this policy.

    • Examples include IB Stim, First Relief v1, and TEA Device.
    Denial Risk

    Requests for covered indications may be denied

    Requests for percutaneous electrical nerve field stimulation for abdominal pain-related disorders of gut-brain interaction, including irritable bowel syndrome and functional dyspepsia, may be denied because the service is identified as investigational. The policy scope was expanded from irritable bowel syndrome to include abdominal pain-related disorders of gut-brain interaction.

    • The current policy statement applies to conditions including irritable bowel syndrome and functional dyspepsia.

    Clinical Background

    Percutaneous electrical nerve field stimulation delivers electrical impulses through percutaneous electrodes placed near cranial nerve branches behind the ear, targeting brain areas involved in pain processing. The service uses a non-implantable, disposable, battery-operated device connected to a four-lead electrode array.

    Key Definitions

    Disorders of gut-brain interaction
    DefinitionConditions in which the stomach and intestines do not work as expected, even though no clear structural problem is found.
    Common examplesIrritable bowel syndrome and functional dyspepsia.
    Typical symptomsOngoing pain, bloating, or discomfort.
    Percutaneous electrical nerve field stimulation
    Device typeNon-implantable, disposable, and battery-operated.
    Stimulation methodStimulates nerves remotely from the site of pain using a percutaneous electrical nerve field stimulator.
    Electrode array
    Policy Summary
    PayerPremera Blue Cross of Washington
    PolicyPercutaneous Electrical Nerve Field Stimulation for Disorders of Gut-Brain Interaction
    Policy CodePolicy 2.01.106
    Change TypeModified
    Effective DateNovember 6, 2026
    Last ReviewAug 1, 2026
    Next Review DateN/A
    Key ActionTreat requests for percutaneous electrical nerve field stimulation for abdominal pain-related disorders of gut-brain interaction as investigational and subject to denial.
    SourceLink
    On This Page
    Coverage CriteriaCoding InformationProvider GuidanceClinical BackgroundKey Definitions
    A four-lead electrode array with thin needles attaches behind the ear at points where cranial nerve peripheral branches are located just beneath the skin.
    Rome IV abdominal pain-related disorders of gut-brain interaction
    ClassificationRome IV classifies abdominal pain-related disorders of gut-brain interaction across gastrointestinal, bowel, centrally mediated pain, gallbladder and sphincter of Oddi, anorectal, and childhood functional disorder categories.
    Functional dyspepsiaIncludes postprandial distress syndrome and epigastric pain syndrome.
    Irritable bowel syndromeListed under the Rome IV bowel disorders category and among childhood functional abdominal pain disorders.
    Other examplesFunctional constipation, functional diarrhea, functional abdominal bloating or distension, and centrally mediated abdominal pain syndrome.