BlueCross BlueShield of Tennessee Medical Policy Manual

General Policy for Neurological Disorders, Pain, Depression, and Nausea Diagnosed or Treated with Electrical Nerve Stimulation

PURPOSE

To establish a basis for determining appropriate applications of electrical nerve stimulation (ENS) in the diagnosis and treatment of neurological disorders, depression, pain or nausea.

DESCRIPTION

Electrical nerve stimulation has been investigated as a means of diagnosing and treating some neurological disorders, pain, depression and nausea/vomiting. ENS involves the internal or external application of a generator that transmits an electrical charge via lead wires to electrodes placed at specific points on or within an individual's body.

POLICY

• BlueCross BlueShield of Tennessee recognizes the need for consistency in the determination of medical appropriateness for applications of electrical nerve stimulation.

• Services will be considered medically appropriate only if they have met BlueCross BlueShield of Tennessee's technology evaluation criteria.

DIAGNOSTICS:

• Computed Tomography (CT) Perfusion Imaging

• Electrocorticography (ECoG)

• Evoked Potential Measurements for Erectile Dysfunction

• Intracardiac Electrophysiologic Studies

• Intraoperative Neurophysiologic Monitoring

• Magnetoencephalography and Magnetic Source Imaging of the Brain

• Needle Electromyography (EMG)

• Nerve Conduction Studies

• Quantitative Sensory Testing

• Somatosensory Evoked Potentials (Non-intraoperative)

• Surface Electromyography (sEMG)

• Telemedicine Transmission of Electroencephalograms (EEGs)

• Topographic Brain Mapping

THERAPEUTICS:

• Acupuncture

• Baroreflex Stimulation Devices

• Biofeedback and Neurofeedback

• Biventricular Pacemakers for the Treatment of Heart Failure

• Cochlear Implant

• Cranial Electrotherapy Stimulation and Transcranial Magnetic Stimulation for the Treatment of Depression and Other Psychiatric/Neurologic Disorders

• Deep Brain Stimulation for the Treatment of Movement Disorders

• Electrical Bone Growth Stimulation

• Electrical Stimulation and Electromagnetic Therapy for the Treatment of Wounds

• Electrophrenic Pacemaker

• Interferential Current Stimulation for the Treatment of Pain

• Low Level Laser Therapy (LLLT)

• Neuromuscular Electrical Stimulation

• Occipital Nerve Stimulation

• Pelvic Floor Stimulation

• Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT)

• Posterior Tibial Nerve Stimulation (PTNS) for Voiding Dysfunction

• Sacral Nerve Neuromodulation / Stimulation for Pelvic Floor Dysfunction

• Spinal Cord Stimulation for Treatment of Pain

• Sympathetic Therapy for the Treatment of Pain

• Transcutaneous Electrical Nerve Stimulation (TENS)

• Transcutaneous Electrical Nerve Stimulation (TENS) for the Treatment of Nausea and Vomiting

• Ultrasound Accelerated Fracture Healing Device

• Vagus Nerve Stimulation for Treatment of Depression

• Vagus Nerve Stimulation for the Treatment of Medically Refractory Movement Disorders, Headaches and Obesity

• Visual and Auditory Evoked Potentials

ORIGINAL EFFECTIVE DATE:  11/8/1999

MOST RECENT REVIEW DATE:  6/22/2011

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

This document has been classified as public information.