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    v1.0.28
    OpenPayerPolicy UpdatesGastroenterologySelect Health auricular stimulation Coverage Updat…
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    Currentselect_healthPolicy CCP.1482

    Auricular Stimulation for Abdominal Pain From Irritable Bowel Syndrome

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    Coverage criteria for percutaneous auricular (IB-Stim) nerve field stimulation to treat functional abdominal pain from irritable bowel syndrome in pediatric members and related policy considerations for Select Health of South Carolina.

    Policy Summary
    Payerselect_health
    PolicyAuricular Stimulation for Abdominal Pain From Irritable Bowel Syndrome
    Policy CodePolicy CCP.1482
    Change TypeMaterial coverage change — investigational to medically necessary (pediatrics only)
    Effective DateApr 1, 2021
    Last ReviewMar 1, 2026
    Next Review DateJul 1, 2027
    Key ActionObtain prior authorization and document failure of gut‑brain psychotherapies and other conservative measures before requesting auricular stimulation for members age 4–18.
    SourceLink
    POLICY UPDATE CHANGES

    Policy changed from investigational to medically necessary for children based on a new guideline recommending percutaneous electrical nerve field stimulation for refractory IBS pain in children.

    Explicit coverage statement that auricular stimulation may be medically necessary for members age 4 to 18 years who have not achieved adequate pain relief with gut-brain psychotherapies and other conservative measures.

    List of contraindications including cardiac pacemaker, hemophilia, and psoriasis vulgaris.

    age 4-18 yearscovered population
    120 hrs/wk, up to 4 wksintended device use duration

    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.

    1 RCT + post-hocsupporting studies
    no serious AEssafety signal
    64567commonly submitted code

    Coverage Criteria

    Initial therapy (pediatric)

    Covered when ALL of the following are met

    Age: Member age is between 4 and 18 yearsage 4-18

    Policy limits coverage to pediatric population per guideline

    Diagnosis: Functional abdominal pain related to irritable bowel syndromeclinical diagnosis of IBS/functional abdominal pain

    Refer to guideline recommending use in children with IBS-related functional abdominal pain

    Prior therapies: Inadequate pain relief after gut-brain psychotherapies and other conservative measures (e.g., lifestyle/dietary modification, cognitive behavioral therapy, hypnotherapy) and appropriate pharmacologic trials as indicatedfailure of conservative/gut-brain therapies

    Guideline-based prerequisite: used for children who have shown considerable difficulty achieving pain relief with these measures

    Device use intent: Use of percutaneous auricular (auricular percutaneous electrical nerve field) stimulation (e.g., IB-Stim) combined with other therapies as indicatedtreatment duration per device labeling (intended 120 hours/week up to 4 weeks)

    Aligned with device labeling and FDA clearance and guideline recommendation

    Auricular percutaneous electrical nerve field stimulation is contraindicated in members with any of the following conditions: a cardiac pacemaker, hemophilia, or psoriasis vulgaris. These contraindications are specified by the device manufacturer and reflected in the policy limitations due to lack of clinical data and safety considerations.

    Use of auricular percutaneous electrical nerve field stimulation for adults is considered not supported / not covered because the body of evidence for safety and efficacy in adult populations is limited and inadequate, and professional guidelines do not endorse routine use in adults outside of research settings.

    Provider Actions & Requirements

    Prior Authorization

    Prior authorization required

    Prior authorization is expected for auricular percutaneous electrical nerve field stimulation (commonly billed as CPT 64567) to confirm medical necessity for members age 4–18 years after failure of gut-brain psychotherapies and other conservative measures.

    • Procedure commonly billed as CPT 64567
    Step Therapy

    Conservative therapy prerequisite

    Require prior trial of conservative measures including lifestyle and dietary modification, gut‑brain psychotherapies (for example, hypnotherapy or cognitive behavioral therapy), and appropriate pharmacologic trials as indicated before considering auricular stimulation.

    • Gut‑brain psychotherapies explicitly cited: hypnotherapy, cognitive behavioral therapy
    • Include lifestyle/dietary modification and pharmaceuticals as appropriate

    Coding

    Commonly submitted procedure codesCPT
    64567Percutaneous electrical nerve field stimulation, cranial nerves, without implantation

    Background

    Functional abdominal pain related to irritable bowel syndrome in children has few well-supported pharmacologic options, prompting growing interest in nonpharmacologic approaches such as psychosocial and mind–body therapies and neuromodulation techniques including percutaneous auricular nerve field stimulation. The NeurAxis IB‑Stim device is an FDA‑cleared Class II, non‑implanted percutaneous auricular stimulator for patients age eight years and older that applies low‑voltage current to cranial and occipital nerve fields and is intended for up to 120 hours per week for four consecutive weeks. Evidence supporting use in pediatric populations includes a randomized, double‑blind, sham‑controlled trial and guideline recommendations that led to the policy change from investigational to medically necessary for children with refractory IBS‑related abdominal pain; evidence in adults remains limited.

    Definitions

    IB-Stim (NeurAxis IB-Stim) — device definition and FDA status
    Device name and manufacturerNeurAxis IB-Stim (formerly Neuro-Stim) — NeurAxis, Inc., Carmel, Indiana
    Device class and implantation statusFDA-cleared Class II, non-implanted percutaneous auricular nerve stimulator
    FDA-cleared indication (age and condition)Cleared for use in patients age 8 years and older to reduce functional abdominal pain and functional dyspepsia associated with irritable bowel syndrome when combined with other therapies
    Stimulation targets and methodApplies low-voltage electrical current to branches of cranial nerves V, VII, IX, and X and the occipital nerve field around the ear identified by transillumination
    Intended use duration per labelingIntended to be used 120 hours per week for up to four consecutive weeks
    Contraindications noted in labelingContraindicated in patients with a cardiac pacemaker, hemophilia, and psoriasis vulgaris
    Policy Summary
    Payerselect_health
    PolicyAuricular Stimulation for Abdominal Pain From Irritable Bowel Syndrome
    Policy CodePolicy CCP.1482
    Change TypeMaterial coverage change — investigational to medically necessary (pediatrics only)
    Effective DateApr 1, 2021
    Last ReviewMar 1, 2026
    Next Review DateJul 1, 2027
    Key ActionObtain prior authorization and document failure of gut‑brain psychotherapies and other conservative measures before requesting auricular stimulation for members age 4–18.
    SourceLink
    On This Page
    Coverage CriteriaProvider Actions & RequirementsCodingBackgroundDefinitions
    Documentation Required

    Required clinical documentation

    Document prior conservative therapies attempted (including gut‑brain psychotherapies such as hypnotherapy or cognitive behavioral therapy) and the clinical indication of refractory functional abdominal pain consistent with IBS; supporting trial data and device FDA clearance information may be referenced.

    • Record specific therapies tried and duration/response
    • Include clinical evidence of refractory functional abdominal pain and any relevant trial results
    Denial Risk

    Denial triggers

    Requests may be denied if the member is outside the covered pediatric age range (4–18 years) or has contraindications such as a cardiac pacemaker, hemophilia, or psoriasis vulgaris.

    • Age outside 4–18 years is not covered under the pediatric indication
    • Contraindications: cardiac pacemaker, hemophilia, psoriasis vulgaris
    Percutaneous electrical nerve field stimulation (auricular stimulation) — procedural definition
    Procedure namePercutaneous electrical nerve field stimulation (auricular stimulation)
    Procedure descriptionApplication of periauricular percutaneous electrodes delivering low‑voltage electrical stimulation to auricular nerve fields (branches of cranial nerves and occipital nerve field) as a neuromodulatory treatment for functional abdominal pain
    Typical device usedNeurAxis IB‑Stim percutaneous auricular nerve stimulator (FDA‑cleared device used in studies and labeling)
    Intended clinical contextUsed as adjunctive therapy combined with other treatments for IBS‑related functional abdominal pain
    Use parameters from labelingDelivered to auricular nerve fields identified by transillumination; intended regimen 120 hours/week for up to 4 weeks
    Contraindications relevant to procedureNot performed in patients with cardiac pacemaker, hemophilia, or psoriasis vulgaris per device labeling