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ModifiedSelectHealthPolicy 443

Acute Inpatient Rehabilitation (IRF) coverage

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SelectHealth policy describing coverage criteria, requirements, and applicable conditions for acute inpatient rehabilitation (IRF) admissions for commercial, Medicare (when CMS criteria absent), and Select Health Community Care plans. Affects providers requesting or delivering inpatient rehabilitation services.

Policy Summary

PayerSelectHealth

PolicyAcute Inpatient Rehabilitation (IRF) coverage

Policy CodePolicy 443

Change TypeCoverage clarifications and criteria revisions

Effective DateJun 28, 2023

Last ReviewFeb 11, 2026

Next Review DateN/A

Key ActionVerify member benefits and obtain prior authorization, ensuring documentation shows all coverage criteria are met before requesting IRF admission or BIS for early lymphedema.

SourceLink

POLICY UPDATE CHANGES

Revised to include coverage of this procedure when criteria are met for early lymphedema related only to breast cancer (was previously covered in these circumstances for both breast cancer and melanoma).

Clarified requirements in coverage criteria: 'Select Health covers bioimpedance spectroscopy only for the evaluation or diagnosis of early lymphedema, defined as Stage 0 or 1, related to breast cancer or melanoma.'

For Commercial Plan Policy, changed qualifying condition for this therapy of traumatic brain injury (TBI) to acquired brain injury (ABI), which allows inclusion of non-traumatic brain injuries as well.

Clarified requirements in criterion #1h: 'Test (e.g., trial) dosing has been successful; this requirement does not apply to cancer patients.'

For Commercial Plan Policy, physical therapy requirement clarified to a minimum of 12 visits within a 6-month period, performed within the previous year, with at least four recommended in-person; after 6 visits additional therapy is not required if contraindicated or not recommended by the physical therapist.

Removed previous requirements pertaining to intrathecal baclofen therapy for Commercial Plan Policy because those requirements are outlined in medical policy #137.

3 hrsmin active therapy/day

15 hrsmin weekly therapy

ALL must be metcoverage logic

Breast cancer onlyBIS coverage (commercial)

12 visitsPT requirement (pumps)

Coverage Criteria and Determinations

Criteria for coverage (ALL must be met)

Covered when ALL of the following are met

IRF coverage criteria: 1. Requires close medical supervision by a physiatrist or other physician qualified by specialized training and experience in inpatient rehabilitation to monitor the patient’s medical condition.

IRF coverage criteria: 2. Medical conditions are sufficiently stable to be reasonably managed in an inpatient rehabilitation facility and allow routine participation in a structured rehabilitative program.

IRF coverage criteria: 3. Requires multidisciplinary care (e.g., physical therapy, occupational therapy, speech/language pathology, psychosocial services) to achieve optimal functional recovery with a minimum of three (3) hours active participation daily.>=3 hours/day

Minimum staffing and therapy frequency expectations described in facility requirements.

IRF coverage criteria: 4. Patient is physically and cognitively capable and willing to participate in at least 3 hours of an intensive physical rehabilitation program per day.

IRF coverage criteria: 5. Clearly written functional goals are defined by a program manager within 5 days of admission, with documentation of discharge planning and progression toward goals.within 5 days

IRF coverage criteria: 7. Patient has a community-based environment and available care providers with a high likelihood of successful reintegration.

IRF coverage criteria: 8. Patient has been evaluated and accepted by the admitting physician or designee as meeting the above requirements.

BIS Coverage (Commercial/CHIP)

Covered when ALL of the following are met

BIS for early lymphedema (commercial/CHIP): Bioimpedance spectroscopy (BIS; CPT 93702) is covered only for the evaluation or diagnosis of early lymphedema, defined as Stage 0 or Stage 1, related to breast cancer.Stage 0 or 1

For all other indications BIS is considered experimental/investigational.

Initial evaluation for early lymphedema

Covered when ALL of the following are met

Coverage criteria: 1) Patient is at risk for or being evaluated for early lymphedema (Stage 0 or Stage I). 2) Lymphedema is related to breast cancer (policy revised to limit coverage to breast cancer-related early lymphedema). 3) Use of bioimpedance spectroscopy (93702) is for evaluation/diagnosis as outlined in policy. 4) Documentation supports the indication and medical necessity per policy and member benefits at time of request.

Revision history documents change to limit coverage to breast cancer-related early lymphedema.

Evidence-supported coverage stance

Covered when consistent with conservative, evidence-informed management of musculoskeletal conditions

Conservative multidisciplinary care: Spinal manipulation/chiropractic care is supported as a component of first-line, nonpharmacologic, conservative management for acute and chronic low back pain and other neuromusculoskeletal complaints when provided as part of a multidisciplinary approach (often combined with exercise and usual medical care).

Supported by ACP, Lancet and other evidence summaries noting benefit and safety; consider as part of conservative spine care pathway.

Covered Indications

Covered when ALL of the following are met

Covered Indication: Patient has suffered either a cerebrovascular accident (CVA, stroke) OR an acquired brain injury (ABI).

Cognitive rehabilitation coverage is limited to these conditions when provided as part of comprehensive rehabilitation.

Service Context: Cognitive rehabilitation is provided as part of a comprehensive physical, occupational, and/or speech rehabilitation/therapy program.

Coma stimulation is explicitly not covered.

Evidence summary (functional outcomes and device comparisons)

Evidence and observed outcomes in reviewed studies

Evidence summary: Multiple small within-subject and crossover studies of microprocessor-controlled knees (e.g., C-Leg, C-Leg Compact) report subjective preference, reductions in falls, and improvements on select functional tasks (e.g., stair/ramp descent). Evidence for newer devices (e.g., Genium) is limited to biomechanical data; some devices (e.g., Rheo Knee II) showed little difference in small studies.

Study-level findings are summarized; these are not prescriptive coverage thresholds.

Medical Necessity (Commercial and CHIP)

Select Health considers CIMT medically necessary only when ALL the following are met for post-stroke patients:

CIMT Medical Necessity Criteria: 1) Patient is a post-stroke patient with upper limb hemiparesis; 2) Patient has at least 10 degrees of active wrist and finger extension; 3) Patient has no sensory deficits; 4) Patient has no cognitive deficits.≥ 10 degrees active wrist and finger extension

These criteria apply to CIMT for post-stroke upper limb hemiparesis; other indications are investigational.

Therapeutic facet joint injection criteria

Covered when ALL of the following are met

Initial therapeutic steroid facet joint injection allowed when: the applicable general criteria (section I 1-4) have been met; and the patient has had two diagnostic anesthetic facet joint injections at the same level(s) and side; and the medical record confirms each diagnostic injection provided ≥ 80% pain relief with duration consistent with the agent used.diagnostic blocks ≥ 80% pain relief

Two diagnostic blocks required to confirm facet-mediated pain.

Subsequent therapeutic steroid facet joint injections: Subsequent injections at the same level/side allowed when prior therapeutic injections resulted in ≥ 50% reduction in facet-related pain OR ≥ 50% improvement in ability to perform previously painful movements/ADLs, and benefit lasted at least 3 months.Maximum 4 injections per rolling 12 months

Benefit duration and response must be documented.

Radiofrequency ablation criteria

Covered when ALL of the following are met

Primary RFA: Non-pulsed thermal radiofrequency ablation (RFA) of sacral (S1 only), cervical, and lumbar facet joints allowed when: applicable general criteria are met and diagnosis of facet joint pain is confirmed by a controlled, two-step medial branch block performed under local anesthetic fluoroscopic guidance without analgesics, with ≥ 80% pain reduction consistent with anesthetic duration for each block.diagnostic MBBs ≥ 80% pain relief

S1 only for sacral; two-step controlled MBB required.

Repeat RFA at the same level/side allowed when patient experienced ≥ 50% reduction in facet-related pain OR ≥ 50% improvement in ability to perform previously painful movements/ADLs from prior RFA, and at least 6 months have passed since prior RFA.≥ 6 months since prior RFA

Repeat RFA does not require further PT or chiropractic therapy.

Acute therapy exception

Covered when ALL of the following are met

Acute single-level therapy: Single-level therapeutic facet intervention is allowed for severe, acute facet-mediated pain provoked by facet maneuvers; two injections are allowed within 3 months and two diagnostic blocks are not required for this acute therapy.two injections within 3 months

Designed as an acute exception to usual diagnostic block requirements.

Facet cyst aspiration criteria

Covered when ALL of the following are met

Facet cyst aspiration/rupture: Intra-articular facet joint injection with synovial cyst aspiration/rupture is medically necessary when advanced imaging (e.g., MRI/CT/myelogram) confirms compression or displacement of the corresponding nerve root by the facet joint synovial cyst AND clinical/physical symptoms of radiculopathy are documented.

Aspiration/rupture may be repeated once if prior procedure resulted in ≥ 50% pain reduction for at least 3 months.

Not Covered — Epidural Adhesiolysis

Coverage determination

Not covered for Commercial and CHIP: Select Health does NOT cover lysis of epidural adhesions (percutaneous Racz procedure or endoscopic adhesiolysis) for any indication; the technology is considered experimental/investigational due to weak and inconsistent evidence.

Claims for CPT 62263 and 62264 will be denied when billed for this indication.

Not Covered / Experimental

Coverage determination for epidural adhesiolysis in this policy segment:

Main coverage stance: Epidural adhesiolysis (percutaneous or endoscopic) for the treatment of chronic back pain is considered experimental/investigational and not covered for this indication.

Billing/Coding information lists the procedure as Not covered: Experimental/Investigational/Unproven.

Not covered (Functional anesthetic discography)

Functional anesthetic discography

Commercial/CHIP stance: Select Health does NOT cover functional anesthetic discography; it is considered experimental/investigational.

Not covered (FES/NMES)

Functional electrical stimulation / Neuromuscular electrical stimulation

Commercial/CHIP stance: Select Health does NOT cover functional electrical stimulation (FES) or neuromuscular electrical stimulation (NMES); these are considered experimental/investigational for the indicated uses.

Evidence is mixed and limited in many indications.

Application rules for public plans

Medicare and Community Care (Medicaid) application

Medicare: Coverage for Medicare beneficiaries is determined by CMS; if CMS has not adopted a determination and InterQual criteria are not available, the Select Health Commercial policy applies.

Providers should reference CMS determinations when applicable.

Community Care (Medicaid): Select Health Community Care policies typically align with the State of Utah Medicaid policy; where no state published position exists, Select Health Commercial criteria will apply.

Providers should reference state Medicaid resources for the most current coverage.

Not Covered / Investigational

Coverage and medical necessity determinations in this section are summarized from the evidence review and coding statements.

Not-covered/Investigational for certain indications: Functional electrical stimulator systems and related transcutaneous stimulation are listed as investigational/experimental/unproven for the stated indications and are not covered.

Denial risk for services characterized as investigational.

Commercial and CHIP Coverage Criteria

Covered when ALL of the following are met

Covered indications and prerequisites: 1) Member has chronic anorectal pain associated with radiation proctitis OR chronic coccydynia; AND 2) Member has failed at least 3 months of conservative therapy (e.g., NSAIDs, local analgesics, modified coccygeal cushions).failed >= 3 months conservative therapy

Maximum of four ganglion impar blocks per rolling 12 months.

Covered Indications and Criteria for implantable infusion pumps

SelectHealth covers implantable infusion pumps in the following circumstances:

Continuous chemotherapy administration: Implantable infusion pumps are covered when they are appropriate for individuals requiring continuous administration of chemotherapy drugs (e.g., intrahepatic floxuridine for limited liver metastases).

See intrahepatic chemotherapy indication and device labeling requirements.

Chronic pain management: Covered when ALL of the following are met: (a) Treatment managed by a certified physician pain specialist; (b) More conservative methods have failed, including: (1) OTC drugs (e.g., NSAIDs); (2) Physical therapy: minimum of 12 visits within a 6-month period performed within the previous year (recommended >=4 in-person); after 6 visits, additional therapy not required if contraindicated or not recommended by the therapist; (3) Psychological/behavioral therapies; (4) Pain interventions are contraindicated or have failed; (c) Further surgical intervention is not indicated or pump therapy has better likelihood of success (50%-75% or better); (d) Pain is not completely neuropathic in origin; (e) No surgical contraindications; (f) Psychological clearance obtained (not required for malignant pain); (g) Documented long-term follow-up plan managed by a certified pain specialist; (h) Successful trial/test dosing (does not apply to cancer patients).PT >= 12 visits/6 months

Requirements 2-b(1-4) do not apply to cancer patients.

For SelectHealth Medicare (CMS) beneficiaries, CMS determinations apply when a Medicare coverage decision exists; when CMS has not adopted a determination and InterQual criteria are not available, the SelectHealth commercial policy will apply. Providers should reference CMS guidance for Medicare members and the SelectHealth commercial policy or InterQual only when no CMS position exists.

Bioimpedance spectroscopy (BIS) is considered experimental/investigational for all indications except when used for the evaluation or diagnosis of early lymphedema (Stage 0 or Stage I) related to breast cancer. Use of BIS outside this specific indication may be denied as not medically necessary under commercial and CHIP plans.

Policy revision history documents that coverage for BIS was previously extended to early lymphedema related to both breast cancer and melanoma, but was revised on 6/11/25 to limit commercial plan coverage to early lymphedema related only to breast cancer. Verify member-specific applicability for dates of service around revision entries.

The lists of CPT/HCPCS/ICD codes in this policy are provided for informational purposes only. Inclusion or exclusion of codes does not guarantee member coverage or provider reimbursement; coverage and payment depend on the member's individual contract and benefits in effect at the time services are rendered. Providers should always verify eligibility and prior authorization requirements before delivering services.

SelectHealth explicitly states that coma stimulation (HCPCS S9056) is not covered and is classified as investigational/experimental for the indicated use. Claims for this service may be denied under commercial and CHIP policies.

The presence of a procedure, diagnosis, or device code in the policy document is informational only. Policy inclusion/exclusion of codes does not imply coverage or reimbursement; providers must confirm benefits and any preauthorization requirements with SelectHealth for each member prior to billing.

The policy notes limited or mixed evidence for some devices; for example, the small study cited for the Rheo Knee II showed little difference compared with non–microprocessor knees, indicating limited or no evidence of clinically meaningful benefit for certain devices. Such evidence limitations inform the policy's coverage stance.

SelectHealth considers constraint-induced movement therapy (CIMT) investigational for indications other than post-stroke upper limb hemiparesis (for example, traumatic brain injury or cerebral palsy). Only the specified post-stroke criteria meet medical necessity; other uses are not covered.

Radiofrequency ablation (RFA) of thoracic facet joints is not covered as experimental/investigational (except where specified for select self-funded groups). Diagnostic medial branch blocks and diagnostic facet injections performed solely as precursors to thoracic RFA are also not covered. In addition, the policy labels related procedural entries as Not covered: Experimental/Investigational/Unproven in the billing/coding section.

All other denervation techniques beyond the specified non-pulsed thermal RFA for chronic cervical and lumbar facet pain (for example, pulsed RFA, laser, cryodenervation, chemical denervation) are considered investigational and are excluded from coverage under this policy.

SelectHealth does not cover lysis of epidural adhesions—whether performed percutaneously (e.g., Racz procedure) or endoscopically—for any indication. Claims for CPT codes 62263 and 62264 will be denied because the procedure is considered experimental/investigational.

Epidural adhesiolysis is explicitly listed as excluded and characterized as Experimental/Investigational/Unproven for this indication in both the commercial/CHIP coverage section and the billing/coding information; providers should not expect coverage for these procedures.

SelectHealth states that functional anesthetic discography is not covered and meets the plan's definition of experimental/investigational for commercial and CHIP plans; corresponding discography CPT codes are listed under not covered procedures.

Functional electrical stimulation (FES) and neuromuscular electrical stimulation (NMES) — including full-system or system-level FES devices (e.g., HCPCS E0764) — are classified as not covered: investigational/experimental/unproven for the indications addressed in this policy. The billing/coding section reiterates the investigational stance and absence of identified CPT codes for covered FES services.

The policy references system-level FES devices (HCPCS E0764) as part of the discussion of functional electrical stimulation. While the HCPCS code is listed in coding tables, the document classifies these systems as not covered / investigational for the stated indications.

Coverage for procedures such as ganglion impar blocks is limited to the specific indications listed (for example, chronic anorectal pain associated with radiation proctitis or chronic coccydynia) and only when the member has failed at least 3 months of conservative therapy. Services outside those listed indications or failing to meet the prerequisites are not covered.

SelectHealth considers implantable infusion pumps medically necessary only for specified indications (for example, intrahepatic chemotherapy for selected liver metastases and certain continuous chemotherapy uses). The policy states that implanted pumps are experimental/investigational for all other indications not explicitly covered in the policy.

Codes and Billing

CPT CODESCPT

No codes listed

HCPCS CODESHCPCS

No codes listed

Covered CPT Codes - BISCPTCovered

93702

Bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema assessment(s)

Relevant ICD-10 Codes (breast neoplasms and related)ICD-10

C50.812	Malignant neoplasm of overlapping sites of left female breast
C50.819	Malignant neoplasm of overlapping sites of unspecified female breast
C50.821	Malignant neoplasm of overlapping sites of right male breast
C50.822	Malignant neoplasm of overlapping sites of left male breast
C50.829	Malignant neoplasm of overlapping sites of unspecified male breast
C50.911	Malignant neoplasm of unspecified site of right female breast
C50.912	Malignant neoplasm of unspecified site of left female breast
C50.919	Malignant neoplasm of unspecified site of unspecified female breast
C50.921	Malignant neoplasm of unspecified site of right male breast
C50.922	Malignant neoplasm of unspecified site of left male breast

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Modalities and therapeutic proceduresCPT

97012	Application of a modality to 1 or more areas; traction, mechanical
97014	Application of a modality to 1 or more areas; electrical stimulation (unattended), each 15 minutes
97024	Application of a modality to 1 or more areas; diathermy (eg, microwave)
97028	Application of a modality to 1 or more areas; ultraviolet
97032	Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes
97033	Application of a modality to 1 or more areas; iontophoresis, each 15 minutes
97035	Application of a modality to 1 or more areas: ultrasound, each 15 minutes
97110	Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises
97112	Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception
97116	Gait training (includes stair climbing)

Additional therapeutic procedure codesCPT

97124	Therapeutic procedure; massage
97140	Manual therapy techniques; note: should not be billed when manipulation is performed on same area
97530	Therapeutic activities, direct (one-to-one) patient contact

Manipulation (CMT) CodesCPTCovered

98940	Chiropractic manipulative treatment (CMT); spinal, one to two regions
98941	Chiropractic manipulative treatment (CMT); spinal, three to four regions
98942	Chiropractic manipulative treatment (CMT); spinal, five regions
98943	Chiropractic manipulative treatment (CMT); extraspinal, one or more regions

Surgical/Anesthesia manipulation codeCPT

22505

Manipulation of spine requiring anesthesia, any region

E/M Codes (office visit codes)CPT

99202	Office or other outpatient visit for E/M of a new patient; expanded problem-focused history/exam; straightforward MDM
99203	Office or other outpatient visit for E/M of a new patient; detailed history/exam; low complexity MDM
99204	Office or other outpatient visit for E/M of a new patient; comprehensive history/exam; moderate complexity MDM
99205	Office or other outpatient visit for E/M of a new patient; comprehensive history/exam; high complexity MDM
99211	Office or other outpatient visit for E/M of an established patient; minimal problems
99212	Office or other outpatient visit for E/M of an established patient; problem-focused history/exam; straightforward MDM
99213	Office or other outpatient visit for E/M of an established patient; expanded problem-focused history/exam; low complexity MDM
99214	Office or other outpatient visit for E/M of an established patient; detailed history/exam; moderate complexity MDM
99215	Office or other outpatient visit for E/M of an established patient; comprehensive history/exam; high complexity MDM

Covered CPT Codes (rehab-related)CPTCovered

96125	Standardized cognitive performance testing per hour (including administering tests, interpreting results, preparing report)
97129	Therapeutic interventions that focus on cognitive function, direct (one-on-one) patient contact; initial 15 minutes
97130	Therapeutic interventions that focus on cognitive function, each additional 15 minutes (add-on)

Covered CPT Codes (continued)CPTCovered

97129	Therapeutic interventions that focus on cognitive function, direct (one-on-one) patient contact; initial 15 minutes
97130	Therapeutic interventions that focus on cognitive function, each additional 15 minutes (add-on)

Not covered HCPCS CodesHCPCSNot Covered

S9056

Coma stimulation per diem

Informational codesmixed

No codes listed

CPT CODES (device related)CPT

No codes listed

HCPCS CODES (device related)HCPCS

L5856	Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type
L5857	Addition to lower extremity prosthesis; swing phase only, includes electronic sensor(s), any type
L5858	Addition to lower extremity prosthesis; stance phase only, includes electronic sensor(s), any type
K1014	Addition, endoskeletal knee-shin system, 4 bar linkage or multiaxial, fluid swing and stance phase control
K1022	Addition to lower extremity prosthesis, endoskeletal, knee disarticulation, above knee, hip disarticulation, positional rotation unit, any type
L2006	Knee ankle foot device, any material, single or double upright, swing and stance phase microprocessor control with adjustability, includes all components
L5859	Addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension assist control, includes any type motor(s)

HCPCS CODES (additional device set)HCPCS

L5856	Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type
L5857	Addition to lower extremity prosthesis; swing phase only, includes electronic sensor(s), any type
L5858	Addition to lower extremity prosthesis; stance phase only, includes electronic sensor(s), any type
K1014	Addition, endoskeletal knee-shin system, 4 bar linkage or multiaxial, fluid swing and stance phase control
K1022	Addition to lower extremity prosthesis, endoskeletal, knee disarticulation, above knee, hip disarticulation, positional rotation unit, any type
L2006	Knee ankle foot device, any material, single or double upright, swing and stance phase microprocessor control with adjustability, includes all components
L5859	Addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension assist control, includes any type motor(s)

CPT CODES (additional set)CPT

97799	Unlisted physical medicine/rehabilitation service or procedure
92507	Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual
92508	Treatment of speech, language, voice, communication, and/or auditory processing disorder; group
97110	Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises
97112	Neuromuscular reeducation of movement, balance coordination, kinesthetic sense, posture, and/or proprioception
97140	Manual therapy techniques; one or more regions, each 15 minutes
97530	Therapeutic activities, direct (one-on-one) patient contact

HCPCS CODES (additional set)HCPCS

G0151	Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes
S9131	Physical therapy; in home, per diem

Covered CPT Codes (facet injections & RFA)CPTCovered

64490	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance, cervical or thoracic; single level
64491	Injection(s) ... cervical or thoracic; second level (List separately in addition to code for primary procedure)
64492	Injection(s) ... cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure)
64493	Injection(s) ... lumbar or sacral; single level
64494	Injection(s) ... lumbar or sacral; second level (List separately in addition to code for primary procedure)
64495	Injection(s) ... lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure)
64633	Destruction by neurolytic agent, paravertebral facet joint nerve(s) with imaging guidance; cervical or thoracic, single facet joint
64634	Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance; cervical or thoracic, each additional facet joint
64635	Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance; lumbar or sacral, single facet joint
64636	Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance; lumbar or sacral, each additional facet joint

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HCPCS CodesHCPCS

No codes listed

Not covered CPT Codes (epidural adhesiolysis) - summaryCPTNot Covered

62263	Percutaneous lysis of epidural adhesions using solution injection or mechanical means; multiple adhesiolysis sessions; 2 or more days
62264	Percutaneous lysis of epidural adhesions; 1 day

CPT CODES (neutral listing)CPT

62263	Percutaneous lysis of epidural adhesions using solution injection (e.g., hypertonic saline, enzyme) or mechanical means (e.g., catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 2 or more days
62264	Percutaneous lysis of epidural adhesions; 1 day

HCPCS CODES (neutral listing)HCPCS

J7131

Hypertonic saline solution, 1 ml

Not covered / Experimental codesmixedNot Covered

No codes listed

CPT CODES (Discography procedures) - Not coveredCPTNot Covered

62290	Injection procedure for discography, each level; lumbar
62291	Injection procedure for discography, each level; cervical or thoracic
72285	Discography, cervical or thoracic, radiological supervision and interpretation
72295	Discography, lumbar, radiological supervision and interpretation

HCPCS CODES (placeholder)HCPCS

No codes listed

CPT codes (functional stim system)CPT

No specific CPT codes identified

The document states no specific CPT codes were identified for these services in this section.

HCPCS codes (functional stim system)HCPCS

E0764

Functional neuromuscular stimulation, transcutaneous stimulation of sequential muscle groups of ambulation with computer control, used for walking by spinal cord injured, entire system, after completion of training program

CPT Codes (unlisted nervous procedure example)CPTCovered

64999

Unlisted procedure, nervous system

CPT codes (functional stim system) - implantation/maintenance/refill listCPT

36260	Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir.
36261	Implantation or replacement; non-programmable pump.
36262	Implantation or replacement; programmable pump, including preparation of pump, with or without programming.
62324	Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance.
62325	62324 with imaging guidance.
62326	Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, lumbar or sacral; without imaging guidance.
62327	62326 with imaging guidance.
62350	Implantation, revision or repositioning of tunneled intrathecal or epidural catheter; without laminectomy.
62351	62350 with laminectomy.
62355	Removal of previously implanted intrathecal or epidural catheter.

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HCPCS codes (implantation/maintenance/refill/device list)HCPCS

A4220	Refill kit for implantable infusion pump
C1772	Infusion pump, programmable (implantable)
E0782	Infusion pump, implantable, non-programmable (includes all components)
E0783	Infusion pump, implantable, programmable (includes all components)
E0785	Implantable intraspinal (epidural/intrathecal) catheter used with implantable infusion pump, replacement.
E0786	Implantable programmable infusion pump, replacement (excludes implantable intraspinal catheter).

HCPCS Codes (epidural adhesiolysis adjunct)HCPCS

J7131

Hypertonic saline solution, 1 ml

Minimum therapy participation — key values

Minimum daily participation>= 3 hours active participation daily (minimum 5 days/week)

Provider Requirements, Prior Authorization, and Denial Risks

Prior Authorization

Prior Authorization Required

Prior authorization is required. Providers must demonstrate that ALL coverage criteria are met before services are rendered. Failure to obtain required prior authorization or to meet all criteria may result in claim denial.

Verify member-specific benefits and eligibility prior to scheduling or providing services.
Providers should contact Select Health Provider Relations at 801-442-3692 for questions and confirm any plan-specific prior authorization process.

Prior Authorization

BIS Prior Authorization / Coverage Limitation

Bioimpedance spectroscopy (BIS) requires prior authorization and is covered only for evaluation/diagnosis of early lymphedema (Stage 0 or I) related to breast cancer under Commercial and CHIP plans. BIS for all other indications is considered experimental/investigational and will be denied.

BIS coverage limited to Stage 0 (subclinical) and Stage I (early lymphedema) related to breast cancer.
Requests for BIS for other diagnoses should be expected to be denied as investigational.

Background and Rationale

Inpatient rehabilitation facilities provide intensive, multidisciplinary rehabilitation with 24/7 availability of physicians and nurses experienced in medical rehabilitation. Appropriate IRF candidates require close medical supervision (typically by a physiatrist), medical stability to participate in therapy, the ability and willingness to engage in structured programs of at least 3 hours of active therapy daily (minimum five days per week), written functional goals within five days of admission, and documentation supporting a high probability of measurable functional improvement within 7–14 days. Admission decisions should be supported by physician documentation that considers medical, functional, and discharge planning needs.

Definitions and Terms

Rehabilitation hospital/unit definition

DefinitionA licensed facility providing medical, rehabilitation nursing, and intensive therapy services with 24/7 availability of physicians and nurses trained in medical rehabilitation

Therapy staffingStaff must be sufficient to provide at least 3 hours of therapy per day for a minimum of 5 days/week

Interdisciplinary teamPhysiatrists, nurses (CRRN), PT/OT/SLP, psychologists, social workers and other specialists coordinate care

Coverage criteria (ALL must be met) definition

Coverage logicALL of the specified criteria must be met to consider services covered

Key required elementsPhysiatrist supervision; medical stability; multidisciplinary needs; ability/willingness to participate in >=3 hours/day; written functional goals within 5 days; high probability of measurable improvement within 7–14 days

Policy Revision History

2025-06-11policy_revisionLatest

Revised coverage for bioimpedance spectroscopy (BIS) to limit coverage for early lymphedema to cases related only to breast cancer (previously included melanoma).

2025-03-27policy_clarification

Clarified BIS coverage requirements to state BIS is covered only for evaluation or diagnosis of early lymphedema (Stage 0 or 1) related to breast cancer or melanoma.

Policy Summary

PayerSelectHealth

PolicyAcute Inpatient Rehabilitation (IRF) coverage

Policy CodePolicy 443

Change TypeCoverage clarifications and criteria revisions

Effective DateJun 28, 2023

Last ReviewFeb 11, 2026

Next Review DateN/A

Key ActionVerify member benefits and obtain prior authorization, ensuring documentation shows all coverage criteria are met before requesting IRF admission or BIS for early lymphedema.

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Other uses: Covered when the drug to be administered is reasonable and necessary for the specific patient, medically necessary to deliver via an implanted infusion pump, and the FDA-approved labeling for the pump specifies the drug and indication.

FDA labeling must support the drug/indication.

Intrahepatic chemotherapy for liver metastases: Implantable infusion pumps are medically necessary for administration of intrahepatic chemotherapy (e.g., floxuridine) to members with primary hepatocellular carcinoma or metastatic colorectal cancer limited to the liver.

Interdisciplinary team

Requires multidisciplinary care (PT, OT, SLP, psychosocial services)

Physician supervisionClose medical supervision by a physiatrist or physician experienced in inpatient rehabilitation

Minimum weekly therapy hours

Minimum weekly therapy hours>= 15 hours/week

SchedulingTherapy provided minimum 5 days per week to meet 15 hours/week requirement

Facility staffingStaffing must be sufficient to provide required therapy hours (licensed PT/OT/SLP)

Lymphedema stage — Stage 0 or 1

Covered lymphedema stagesStage 0 or Stage 1 (early/reversible)

Stage 0 descriptionSubclinical: swelling not visible but lymphatic transport impaired; symptoms/subtle tissue changes may be noted

Stage I descriptionEarly visible swelling that subsides with elevation; pitting may be present

Diagnostic block pain relief threshold (>=80%)

Diagnostic block success threshold>= 80% pain relief consistent with anesthetic duration

PurposeConfirms facet joint–mediated pain when achieved with controlled diagnostic medial branch blocks

DocumentationMedical record must confirm relief magnitude and duration consistent with agent used

Therapeutic response threshold for repeat procedures (>=50%)

Therapeutic response for repeat procedures>= 50% pain reduction OR >= 50% improvement in ability to perform previously painful movements/ADLs

Duration requirement (facet injections)Benefit should have lasted at least 3 months for subsequent therapeutic steroid injections

Repeat RFA timingRepeat RFA allowed if criteria met and at least 6 months since prior RFA

Maximum number of procedures (e.g., ganglion impar <=4 per 12 months)

Maximum ganglion impar blocksMaximum of four ganglion impar blocks per rolling 12 months

Facet steroid injections limitA maximum of 4 therapeutic steroid facet joint injections is allowed per rolling 12 months

Repeat procedures guidanceMultiple palliative procedures may be needed but limits apply per rolling 12 months

Likelihood of success threshold (50%-75% or better)

Likelihood of success threshold50%-75% or better (used to compare likelihood of success vs further surgical intervention)

ContextApplied when considering implantable infusion pump therapy for chronic pain

Decision factorUsed alongside documentation of failed conservative therapies and specialist management

Physical therapy requirement (12 visits / 6 months; performed within previous year; at least four recommended in-person)

PT visit minimumMinimum of 12 visits within a 6-month period (performed within the previous year)

In-person recommendationIt is recommended that at least four of the PT visits be performed in-person

After 6 visitsAfter 6 visits, additional therapy is not required if contraindicated or not recommended by the physical therapist

Note

Verify Benefits / Prior Authorization

Always verify member benefits and whether prior authorization is required for the specific member and service. The inclusion of codes in this policy is informational and does not guarantee coverage.

Benefits and eligibility are determined by the member's individual benefit plan in effect at the time of service.
Providers and members may contact Customer Service using the number on the member ID card for benefit questions.

Prior Authorization

Coverage and Benefit Verification

Coverage and benefit verification are the provider's responsibility prior to delivering services. Coverage of specific therapies (for example, cognitive rehabilitation, CIMT, implantable pumps, facet procedures) depends on member contract and plan type.

Confirm commercial, CHIP, Medicare, or Medicaid product rules before treatment.
Prior authorization or pre-certification may be required for inpatient rehabilitation, implantable infusion pumps, radiofrequency ablation, and other interventional procedures.

Note

Medicare Coverage Determination

For Medicare members, coverage determinations are made by the Centers for Medicare and Medicaid Services (CMS). If CMS has not adopted a determination and InterQual criteria are unavailable, the SelectHealth commercial policy applies.

Providers should consult the CMS Medicare Coverage Database for current Medicare coverage positions.
When CMS provides a local or national coverage determination, that determination governs coverage for Medicare members.

Prior Authorization

Prior Authorization / Benefits Determination

Prior authorization and benefits determination must follow the member's contract and product rules. Coverage decisions for Commercial, CHIP, Medicare, and Medicaid (Community Care) may differ.

SelectHealth Community Care (Medicaid) follows Utah State Medicaid determinations; if none exist, commercial criteria apply.
Providers should verify whether InterQual criteria are required or available for the service.

Note

Coverage Application for Medicare/Medicaid

For Medicare and Medicaid (Community Care) members, follow CMS or state Medicaid coverage positions. If no official determination exists, SelectHealth Commercial criteria apply.

Medicare: CMS rules and LCDs/LCD updates take precedence.
Medicaid: State Medicaid policies govern; where absent, commercial policy language applies.

Prior Authorization

Prior Authorization for Infusion Pump Services

Providers must verify benefits and obtain any required prior authorization from SelectHealth before procurement, implantation, or billing for infusion pump services. Documentation requirements are strict and prior auth confirms medical necessity.

Prior authorization required for implantation, refill/maintenance, and device supplies for implantable infusion pumps.
HCPCS and CPT codes listed are informational; confirmation of coverage must be obtained per member plan.

Note

Benefit & Coverage Caveat

Inclusion or listing of codes within this policy is informational only and does not imply coverage or reimbursement. Always verify member benefits and preauthorization requirements before providing services.

Codes in policy do not guarantee coverage; check the member's contract in effect at time of service.
SelectHealth updates policies regularly and reserves the right to amend coverage without notice.

Denial Risk

Services Considered Experimental/Investigational

Services identified in this policy as experimental, investigational, or unproven are not covered and may be denied. Examples include coma stimulation, thoracic RFA (except select self-funded groups), epidural adhesiolysis, functional anesthetic discography, and FES/NMES for the listed indications.

Do not expect coverage for procedures labeled investigational; submitting claims without prior auth/documentation may result in denial.
Providers should seek medical necessity justification and confirm coverage only when explicit plan language permits.

Note

Coverage Contingent on Member Benefits

Coverage determinations are contingent on the member's benefits and eligibility at the time of service. Benefits and eligibility are determined before applying medical or payment guidelines.

Always verify eligibility and benefits prior to scheduling or providing care.
Provider Relations and member Customer Service can assist with benefit questions.

Denial Risk

Coverage Limitation and Denial Risk

Coverage limitations and denial risks exist when required clinical criteria are not met. For example, CIMT coverage is limited to post-stroke patients meeting specific motor, sensory, and cognitive criteria; BIS outside of early breast cancer-related lymphedema is denied.

Failure to meet ALL coverage criteria (e.g., medical supervision, stability, participation) may trigger denials.
Requests for services outside stated indications should be expected to be denied.

Denial Risk

Thoracic RFA Exclusion

SelectHealth does NOT cover radiofrequency ablation of thoracic facet joints (except select self-funded groups). Requests for diagnostic facet injections as a precursor to thoracic RFA will also be denied when thoracic RFA is not covered.

Thoracic RFA and associated preparatory procedures are excluded and considered experimental/investigational.
Providers should not submit preauthorization requests for thoracic RFA under standard commercial/CHIP products.

Denial Risk

Denial Risk for Epidural Adhesiolysis

SelectHealth does NOT cover lysis of epidural adhesions (percutaneous or endoscopic) for any indication; this technology is considered experimental/investigational and will be denied.

Expect claims for CPT 62263/62264 or related codes to be denied under Commercial and CHIP plans.
Providers should seek alternative, covered therapies when epidural adhesiolysis is proposed.

Denial Risk

Not Covered — Experimental/Investigational

Procedures deemed experimental/investigational or unproven by the plan are not covered and may be denied. Submit supporting evidence only when a plan exception or self-funded group option exists.

Examples: coma stimulation, many novel denervation techniques, investigational spinal procedures.
Check for self-funded group exceptions before proceeding with requests for excluded services.

Denial Risk

Services Billed as Functional Anesthetic Discography

SelectHealth does NOT cover functional anesthetic discography. Claims submitted for this service may be denied as experimental/investigational under Commercial and CHIP products.

Providers should not expect reimbursement for functional anesthetic discography absent an explicit contract exception.

Denial Risk

Services Billed as Functional Electrical Stimulation (FES/NMES)

SelectHealth does NOT cover functional electrical stimulation/neuromuscular electrical stimulation (FES/NMES) for the indicated uses; these are considered experimental/investigational and may be denied.

Do not bill expecting coverage for FES/NMES absent an explicit plan allowance or exception.

Denial Risk

Investigational/Unproven — Denial Risk

Requests for investigational or unproven services are at high risk of denial. Providers must document clinical rationale and any available evidence when requesting exceptions, but standard policy is to deny investigational services.

Policies list multiple investigational services; confirm whether a self-funded group has opted to cover an otherwise excluded service.

Denial Risk

Conservative Therapy Not Documented — Denial Risk

Failure to document required conservative therapy trials (when specified) may result in denial. For certain procedures (e.g., ganglion impar blocks, implantable pumps), documentation of prior conservative care is mandatory.

Ganglion impar blocks: member must have failed at least 3 months of conservative therapy (NSAIDs, local analgesics, coccygeal cushions) prior to coverage.
Implantable infusion pumps for chronic pain require failure of OTC meds, a minimum of 12 PT visits in 6 months, psychological therapies, and other listed prerequisites (except for malignant pain).

Documentation Required

Physician Decision and Documentation

The physician is responsible for the decision to admit or discharge to IRF level of care and must document the clinical rationale. Final admission decisions require physician judgment supported by medical record evidence.

Document the admitting physician's acceptance of the patient and the clinical reasons supporting IRF admission.
Physician decision should reference applicable criteria (medical stability, need for physiatrist supervision, multidisciplinary services).

Documentation Required

Documentation and Benefits Note

Document medical necessity and benefits verification clearly. The policy's codes are informational; providers must document that services meet policy criteria and verify member benefits before providing care.

Include documentation of physiatrist or qualified physician supervision, patient stability, participation capability, and defined functional goals.
Contact Provider Relations for questions regarding documentation expectations and prior authorization processes.

Documentation Required

Office Visit Documentation Guidance

Office visit and E/M documentation guidance is provided for context. Use appropriate E/M codes and document history, exam, and medical decision-making consistent with the level billed.

Select appropriate E/M CPT codes (e.g., 99202-99205, 99211-99215) and support with clinical documentation.
Documentation should support the medical necessity of referrals, therapy orders, and procedural requisitions.

Note

Benefits and Eligibility Determined First

Benefits and eligibility are determined before applying medical guidelines and payment rules. Verify member coverage and eligibility at the time services are rendered.

Always confirm the member's active plan and covered benefits before initiating treatment.
Coverage determinations may vary by product (Commercial, CHIP, Medicare, Medicaid).

Note

Documentation and Contact

Providers should reference the member's contract benefits and contact SelectHealth Provider Relations with questions. Verification and preauthorization should occur before delivering services to avoid denial.

Provider Relations: 801-442-3692. Members: Customer Service number on ID card.
Preauthorization should be obtained where required and documentation submitted per SelectHealth instructions.

Note

Benefits and Eligibility Note

Benefit and eligibility notes in policies are informational; providers must verify member-specific coverage prior to treatment. Policies do not replace the member contract.

Codes included in policies are for informational purposes only and do not ensure reimbursement.
If a service is covered by CMS or state Medicaid, those determinations govern for Medicare/Medicaid beneficiaries.

Documentation Required

Required Documentation

Required documentation must be submitted with prior authorization requests. Examples include evidence of specialist (e.g., certified pain specialist) management, trial responses, diagnostic block results, psychological clearance, and long-term follow-up plans for implantable devices.

Implantable infusion pumps: document failure of conservative therapies, psychological clearance, trial dosing results, contraindications to surgery, and a long-term follow-up plan.
Facet/RFA: document diagnostic blocks with ≥80% relief and response durations consistent with the anesthetic used; document prior therapeutic benefit for repeat procedures.

Billing Rule

Acute Single-Level Therapy Pathway

Acute single-level therapeutic facet injection pathway: two injections are allowed within a three-month window for severe, acute facet-mediated pain without requiring two diagnostic blocks.

This allowance applies for acute single-level therapy to address severe facet-mediated pain provoked by facet maneuvers.
Subsequent therapeutic injections and repeat RFAs are subject to the stated efficacy and time-since-previous-procedure criteria.

Step Therapy

Conservative Therapy Prerequisites

Conservative therapy prerequisites must be documented prior to approval for many procedures. Examples include trials of OTC medications, minimum physical therapy visits, psychological therapies, and other noninvasive measures.

Document at least 12 physical therapy visits within a 6-month period (with timing and in-person visit recommendations) for implantable pump consideration.
For unmanaged pain, document failure of ≥2 outpatient PT/OT trials and ≥2 pharmacologic/nonpharmacologic treatments where step therapy is required.

Discharge environmentPatient must have a community-based environment and available caregivers for successful reintegration

Bioimpedance Spectroscopy (BIS) / Multiple-Frequency BIA definition

TechniqueMeasures differential impedance to low-level electrical current to evaluate changes in body fluid composition; multiple-frequency BIA often referred to as BIS

Clinical useUsed to evaluate lymphedema (extracellular fluid analysis) and distinguish early changes

CodeCPT 93702 corresponds to bioimpedance spectroscopy for lymphedema assessment

Lymphedema stages definition (Stage 0-III)

Stage 0Subclinical: swelling not visible, lymphatic transport impaired; symptoms/subtle tissue changes may be noted

Stage IEarly lymphedema: visible swelling reversible with elevation; pitting may be present

Stages II–IIIStage II: consistent volume change with pitting and fibrosis; Stage III: significant skin changes, fibrosis, pitting absent

Early lymphedema (Stage 0 or 1) — definition used for BIS coverage

Policy populationEarly lymphedema defined as Stage 0 or 1 is the population for which BIS coverage is provided (commercial/CHIP)

Clinical rationaleNCCN recommends screening with BIS because stages 0 and 1 are reversible with early detection

LimitationsBIS considered experimental/investigational for indications outside early lymphedema related to breast cancer

Spinal manipulation / chiropractic care definition

DefinitionManual therapy provided by chiropractors including spinal manipulation, often combined with exercise and other conservative therapies

Clinical contextUsed as part of a conservative, multidisciplinary approach for neuromusculoskeletal conditions such as low back and neck pain

Guideline supportEndorsed by major guidelines (e.g., ACP, Lancet) as a first-line non-pharmacologic option for low back pain

Conservative spine care pathway definition

ConceptAn early-access, non-surgical approach emphasizing conservative treatments (e.g., chiropractic care, exercise) to reduce downstream imaging, surgeries, and opioid use

ComponentsMay include spinal manipulation combined with exercise, usual medical care, and other conservative modalities

GoalReduce progression to invasive interventions by using conservative multidisciplinary care

Cognitive rehabilitation definition

DefinitionTherapies designed to improve damaged intellectual, perceptual, and behavioral skills (e.g., attention, memory, executive functions)

Service contextProvided as part of comprehensive rehabilitation for stroke or acquired brain injury

Facility prevalenceApproximately 95% of rehabilitation facilities serving brain injury patients provide some form of cognitive rehabilitation

Coma stimulation definition — not covered

DefinitionA stimulation program intended to arouse or stimulate patients in coma or persistent vegetative states; listed in policy as investigational/not covered

Coverage stanceComa stimulation is not covered and is considered experimental/investigational (HCPCS S9056)

Evidence basisPolicy cites lack of conclusive evidence supporting benefit

Policy applicability — SelectHealth product scope

Plan scopeApplies to SelectHealth Commercial, SelectHealth Medicare (CMS), and SelectHealth Community Care (Medicaid); applicability may vary by plan and member benefits

Benefit dependencyCoverage depends on the member's individual benefit plan in effect at time of service

CMS alignmentFor Medicare, CMS determinations apply; if absent, SelectHealth commercial criteria may be used

Medicare Functional Level K2/K3 definition

DefinitionMedicare Functional Level K2/K3: classification levels used to stratify ambulatory ability; outcomes differ between K2 and K3 amputees

Clinical implicationDevice indications (e.g., microprocessor knees) may depend on K-level and functional reserve

Study findingSome studies report reclassification from K2 to K3 after device use (example: 50% reclassification in one study)

CIMT definition

DefinitionConstraint-induced movement therapy (CIMT): therapy that forces/induces use of the impaired limb by constraining the unimpaired limb (e.g., mitt, splint, sling)

Typical protocolTraditional CIMT: constraint worn ~90% of waking hours for 2 weeks with intensive task-specific practice

Modified CIMT (mCIMT)Variations that alter type, duration/frequency, or timing to improve adherence

mCIMT definition

DefinitionModified CIMT (mCIMT): variations of CIMT that change therapy parameters to improve adherence or feasibility

PurposeMaintain therapeutic intent while improving tolerability and compliance

Relation to CIMTmCIMT differs from traditional CIMT in duration/intensity but shares the constrained-use principle

Diagnostic medial branch block (MBB) definition

DefinitionDiagnostic medial branch block (MBB): a controlled anesthetic injection to medial branch nerves to confirm facet joint pain

Positive testConsidered positive when >= 80% pain relief is achieved consistent with anesthetic duration

RoleUsed to select patients for therapeutic facet injections or RFA

Radiofrequency ablation (RFA)/rhizotomy definition

DefinitionRadiofrequency ablation (RFA)/rhizotomy: non-pulsed thermal destruction of nerves innervating the facet joint performed under image guidance

IndicationUsed when facet-mediated pain is confirmed by controlled medial branch blocks

Repeat criteriaRepeat RFA allowed if prior RFA produced >=50% pain reduction or >=50% functional improvement and >=6 months elapsed

Percutaneous epidural adhesiolysis (Racz procedure) definition

DefinitionPercutaneous epidural adhesiolysis (Racz procedure): technique using an RK needle and Racz catheter to enter the epidural space with radiographic guidance to inject solutions and mechanically disrupt adhesions

MethodsMay use hypertonic saline, steroids, local anesthetic and catheter manipulation; catheter may remain for serial sessions

Alternate nameAlso termed epidural neurolysis or Racz neurolysis

Endoscopic epidural adhesiolysis (epiduroscopy) definition

DefinitionEndoscopic epidural adhesiolysis (epiduroscopy): endoscopic placement of a spinal endoscope into the caudal canal to visualize and mechanically perform adhesiolysis and irrigation

TechniqueUses fiberoptic myeloscope with irrigation and mechanical manipulation to lyse adhesions

SynonymsAlso called myeloscopy or spinal epiduroscopy

Epidural adhesiolysis definition

DefinitionEpidural adhesiolysis: percutaneous or endoscopic lysis of epidural adhesions using solution injection (e.g., hypertonic saline, enzyme) or mechanical means (catheter/endoscope)

IndicationInvestigated for epidural fibrosis and failed back surgery syndrome

Coverage stanceSelectHealth does NOT cover epidural adhesiolysis for any indication (considered experimental/investigational)

Functional anesthetic discography definition

DefinitionFunctional anesthetic discography (analgesic discography/discoblock): diagnostic injection using anesthetic to identify discogenic pain

EvidenceLiterature limited; small studies with uncertain validity and clinical utility

Coverage stanceSelectHealth does NOT cover functional anesthetic discography (considered experimental/investigational)

NMES / FES definition

DefinitionNMES/FES: non-invasive surface electrical stimulation applied to muscles to prevent atrophy or produce coordinated movements (e.g., foot drop, cycling)

ApplicationsIncludes NMES for muscle strengthening/atrophy prevention and FES for producing functional movements in stroke/SCI rehabilitation

EvidenceEvidence mixed and limited; SelectHealth considers FES/NMES investigational/not covered for many indications

Functional Electrical Stimulation (FES) definition

DefinitionFunctional Electrical Stimulation (FES): transcutaneous stimulation applied to produce functional movements (e.g., gait, cycling, upper-extremity tasks)

Intended benefitsProvides orthotic (immediate) and therapeutic (long-term) benefits in neurologic/musculoskeletal impairments

Evidence certaintyEvidence generally low to moderate; real-world functional benefit uncertain in many studies

Neuromuscular Electrical Stimulation (NMES) definition

DefinitionNeuromuscular Electrical Stimulation (NMES): transcutaneous stimulation aimed at eliciting muscle contractions to reduce atrophy or improve strength/tonicity

Typical regimensMay be applied nightly for extended periods (e.g., 6–12 hours/night for months) depending on indication

EvidenceConflicting and limited; insufficient evidence to support NMES for muscle atrophy in any population per policy summary

Ganglion impar definition

AnatomyGanglion impar: a midline sympathetic ganglion located just anterior to the upper coccyx supplying sympathetic and nociceptive fibers to perineal and distal pelvic structures

Clinical targetTarget for sympathetic nerve block in coccydynia and pelvic/perineal pain

Procedure intentIntervention considered palliative; patients may require more than one procedure

Coccydynia definition

DefinitionCoccydynia: pain at the coccyx (tailbone) that can be acute or chronic and may persist for months or years

Conservative careMost cases resolve with supportive care; persistent cases may receive coccygeal injections or ganglion impar blocks

Coverage limitSelectHealth covers up to four ganglion impar blocks per rolling 12 months

Implantable infusion pump definition

DefinitionImplantable infusion pump: surgically implanted device that delivers continuous medication (intrathecal, epidural, intrahepatic, or systemic)

Covered usesCovered for continuous chemotherapy administration and select chronic pain indications when criteria are met

ContraindicationsContraindicated with infection, allergy to drug, inadequate body size, or potential device 'crosstalk' with other programmable devices

Revised Commercial Plan Policy to provide coverage of this procedure for certain diagnoses (summary of changes recorded).

2025-06-20policy_revision

For Commercial Plan Policy, changed qualifying condition wording from traumatic brain injury (TBI) to acquired brain injury (ABI), allowing inclusion of non‑traumatic brain injuries.

2025-03-27policy_clarification

Clarified coverage criteria wording for BIS to specify evaluation/diagnosis of early lymphedema (Stage 0 or 1) related to breast cancer or melanoma.

2025-06-11policy_revision

Updated BIS coverage to limit to early lymphedema related only to breast cancer, removing melanoma from covered indications under certain commercial plans.