I'm a member
You will be redirected to myBlue. Would you like to continue?
Please wait while you are redirected.
Please enter a username and password.
Printer Friendly Version
DESCRIPTIONPulsed electrical and electromagnetic stimulation are being investigated to improve functional status and relieve pain related to osteoarthritis (OA) and rheumatoid arthritis (RA) unresponsive to other standard therapies. Electrical stimulation is provided by an electronic device that non-invasively delivers a subsensory low-voltage, monophasic electrical field to the target site of pain. Pulsed electromagnetic fields are delivered via treatment coils that are placed over the skin. See the Electrical Bone Growth Stimulation of the Appendicular Skeleton medical policy.
Electrical stimulation is being investigated to improve functional status and relieve pain related to OA and RA unresponsive to other standard therapies. Noninvasive electrical stimulators generate a weak electrical current within the target site using pulsed electromagnetic fields, capacitive coupling, or combined magnetic fields. In capacitive coupling, small skin pads/electrodes are placed on either side of the knee or wrist. Electrical stimulation is provided by an electronic device that noninvasively delivers a subsensory low-voltage, monophasic electrical field to the target site of pain. Pulsed electromagnetic fields are delivered via treatment coils that are placed over the skin. Combined magnetic fields deliver a time-varying magnetic field by superimposing the time-varying magnetic field onto an additional static magnetic field.
In basic research studies, pulsed electrical stimulation has been shown to alter chondrocyte-related gene expression in vitro and to have regenerative effects in animal models of cartilage injury. Therefore, pulsed electrical stimulation is proposed to be similar to bone stimulator therapy for fracture nonunion.
The BioniCare Bio-1000™ stimulator is a device that has received Food and Drug Administration (FDA) 510(k) marketing clearances to deliver pulsed electrical stimulation for the treatment of osteoarthritis of the knee and rheumatoid arthritis of the hand. The FDA gave the BioniCare Bio-1000™ clearance after finding it to be substantially equivalent to transcutaneous electrical nerve stimulation devices. The BioniCare system consists of an electronic stimulator device with electrical leads that are placed over the affected area and held in place with a lightweight, flexible wrap and Velcro fasteners. The battery-powered device delivers small pulsed electrical currents of 0.0 to 12.0 volt output. It is recommended that the device be worn for at least 6 hours per day, and patients are reported to often wear the device while sleeping. It is proposed that the device treats the underlying cause of the disease by stimulating the joint tissue and improving the overall health of the joint and that it provides a slow-acting, but longer-lasting improvement in symptoms.
The FDA's 510(k) summaries specify the BioniCare Stimulator, Model Bio-1000™ is indicated for use as an adjunctive therapy in reducing the level of pain and:
The BioniCare system is contraindicated in patients with demand-type pacemakers and may interfere with other electronic devices.
The OrthoCor™ Active Knee System (OrthoCor Medical) uses pulsed electromagnetic field energy at a radio frequency of 27.12 MHz to treat pain. The OrthoCor Knee System received marketing clearance from FDA in 2009 and is classified as a shortwave diathermy device for use other than applying therapeutic deep heat (K091996, K092044). It is indicated for adjunctive use in the palliative treatment of postoperative pain and edema in superficial soft tissue and for the treatment of muscle and joint aches and pain associated with overexertion, strains, sprains, and arthritis. The system includes single-use packs (pods) that deliver hot or cold and are supplied in packets of 15. The predicate devices are the OrthoCor (K091640) and Ivivi Torino II™ (K070541).
The SofPulse™ (also Torino II, 912-M10, and Roma3™, Ivivi Health Sciences) received marketing clearance in 2008 as short-wave diathermy devices that apply electromagnetic energy at a radio frequency of 27.12 MHz (K070541). They are indicated for adjunctive use in the palliative treatment of postoperative pain and edema in superficial soft tissue. Palermo is another name for a device marketed by Ivivi Health Sciences.
The Magnetofield (F& B International, Italy) and Elettronica Pagani (Energy Plus Roland Series, Italy) devices provide pulsed electromagnetic field therapy. They are currently marketed in Europe.
POLICYElectrical stimulation is considered investigational for the treatment of osteoarthritis or rheumatoid arthritis.
POLICY EXCEPTIONSFederal Employee Program (FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.
POLICY GUIDELINESInvestigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY7/27/2006: Approved by Medical Policy Advisory Committee (MPAC)
1/24/2008: Policy reviewed, no changes
04/13/2010: Policy title updated to change "Electromagnetic" to "Electrical." Policy description updated regarding research study findings. “501(k)” added to the FDA information in the policy description. Policy statement unchanged. FEP verbiage added to the Policy Exceptions section. Definition of investigative service added to the policy guidelines.
12/29/2010: Policy reviewed; no changes.
11/10/2011: Policy reviewed; no changes.
12/13/2012: Policy reviewed; no changes.
03/11/2014: Policy reviewed; no changes.
01/15/2015: Policy description updated regarding pulsed electrical and electromagnetic stimulation. Added information regarding devices. Policy statement unchanged.
08/18/2015: Medical policy revised to add ICD-10 codes. Removed ICD-9 procedure code 93.39 from the Code Reference section.
SOURCE(S)Blue Cross Blue Shield Association Policy # 1.01.27
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.