Medical Policy Electrostimulation and Electromagnetic Therapy for Treating Wounds

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1 Medical Policy Electrostimulation and Electromagnetic Therapy for Treating Wounds Table of Contents Policy: Commercial Coding Information Information Pertaining to All Policies Policy: Medicare Description References Authorization Information Policy History Policy Number: 655 BCBSA Reference Number: Related Policies Transcutaneous Electrical Nerve Stimulation TENS, #003 Non-Contact Ultrasound Treatment for Wounds, #657 Negative Pressure Wound Therapy in the Outpatient Setting, #543 Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity Electrical stimulation for the treatment of wounds, including but not limited to low-intensity direct current (LIDC), high-voltage pulsed current (HVPC), alternating current (AC), and transcutaneous electrical nerve stimulation (TENS), is INVESTIGATIONAL. Electrical stimulation performed by the patient in the home setting for the treatment of wounds is INVESTIGATIONAL. Electromagnetic therapy for the treatment of wounds is INVESTIGATIONAL. Medicare HMO Blue SM and Medicare PPO Blue SM Members BCBSMA covers electrical stimulation and electromagnetic therapy for the treatment of wounds for the following indications for Medicare HMO Blue and Medicare PPO Blue members in accordance with CMS NCD: Chronic Stage III or Stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers, When performed by a physician, physical therapist, or incident to a physician service. BCBSMA does not cover electrical stimulation and electromagnetic therapy for the treatment of wounds for the following indications for Medicare HMO Blue and Medicare PPO Blue members in accordance with CMS NCD: As an initial treatment modality, 1

2 For continued treatment if measurable signs of healing have not been demonstrated within any 30- day period of treatment, Unsupervised use of ES or electromagnetic therapy for wound therapy. All other uses of ES and electromagnetic therapy not otherwise specified for the treatment of wounds remain at local contractor discretion. National Coverage Determination (NCD) for Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds (270.1) Prior Authorization Information Commercial Members: Managed Care (HMO and POS) This is not a covered service. Commercial Members: PPO, and Indemnity This is not a covered service. Medicare Members: HMO Blue SM Prior authorization is required. Medicare Members: PPO Blue SM Prior authorization is required. CPT Codes / HCPCS Codes / ICD-9 Codes The following codes are included below for informational purposes. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member. A draft of future ICD-10 Coding related to this document, as it might look today, is included below for your reference. Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable. CPT Codes There is no specific CPT code for this service. HCPCS Codes HCPCS codes: G0281 G0282 G0295 G0329 E0761 Code Description Electrical stimulation (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care. Electrical stimulation, (unattended), to one or more areas, for wound care other than described in G0281 Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses. Electromagnetic therapy, to one or more areas, for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care. Non-thermal pulsed high-frequency radiowaves, high peak power electromagnetic energy treatment device. 2

3 E0769 Electrical stimulation or electromagnetic wound treatment device, not otherwise classified. ICD-9 Diagnosis Codes ICD-9-CM diagnosis codes: Code Description Diabetes with neurological manifestations, type II or unspecified type, not stated as Diabetes with neurological manifestations, type I [juvenile type], not stated as Diabetes with neurological manifestations, type II or unspecified type, Diabetes with neurological manifestations, type I [juvenile type], Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as Diabetes with peripheral circulatory disorders, type I [juvenile type], not stated as Diabetes with peripheral circulatory disorders, type II or unspecified type, Diabetes with peripheral circulatory disorders, type I [juvenile type], Diabetes with other specified manifestations, type II or unspecified type, not stated as Diabetes with other specified manifestations, type I [juvenile type], not stated as Diabetes with other specified manifestations, type II or unspecified type, Diabetes with other specified manifestations, type I [juvenile type], Diabetes with unspecified complication, type II or unspecified type, not stated as Diabetes with unspecified complication, type I [juvenile type], not stated as Diabetes with unspecified complication, type II or unspecified type, Diabetes with unspecified complication, type I [juvenile type], Atherosclerosis of native arteries of the extremities with ulceration Varicose veins of lower extremities with ulcer Venous (peripheral) insufficiency, unspecified Pressure ulcer, unspecified site Pressure ulcer, elbow Pressure ulcer, upper back Pressure ulcer, lower back Pressure ulcer, hip Pressure ulcer, buttock Pressure ulcer, ankle Pressure ulcer, heel Pressure ulcer, other site Ulcer of lower limb, unspecified Ulcer of thigh Ulcer of calf Ulcer of ankle Ulcer of heel and midfoot Ulcer of other part of foot Ulcer of other part of lower limb Pressure ulcer, unspecified stage Pressure ulcer, stage III Pressure ulcer, stage IV Pressure ulcer, unstageable 3

4 707.8 Chronic ulcer of other specified sites Chronic ulcer of unspecified site ICD-10-CM Diagnosis Codes ICD-10-CM diagnosis codes: Code Description E10.40 Type 1 diabetes mellitus with diabetic neuropathy, unspecified E10.41 Other specified diabetes mellitus with diabetic mononeuropathy E10.42 Other specified diabetes mellitus with diabetic polyneuropathy E10.43 Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy E10.44 Type 1 diabetes mellitus with diabetic amyotrophy E10.49 Type 1 diabetes mellitus with other diabetic neurological complication E10.51 Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene E10.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene E10.59 Type 1 diabetes mellitus with other circulatory complications E Type 1 diabetes mellitus with foot ulcer E Type 1 diabetes mellitus with other skin ulcer E10.8 Type 1 diabetes mellitus with unspecified complications E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy E11.43 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy E11.44 Type 2 diabetes mellitus with diabetic amyotrophy E11.49 Type 2 diabetes mellitus with other diabetic neurological complication E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene E11.52 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene E11.59 Type 2 diabetes mellitus with other circulatory complications E Type 2 diabetes mellitus with foot ulcer E Type 2 diabetes mellitus with other skin ulcer E11.69 Type 2 diabetes mellitus with other specified complication E11.8 Type 2 diabetes mellitus with unspecified complications E13.40 Other specified diabetes mellitus with diabetic neuropathy, unspecified E13.41 Other specified diabetes mellitus with diabetic mononeuropathy E13.42 Other specified diabetes mellitus with diabetic polyneuropathy E13.43 Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy E13.44 Other specified diabetes mellitus with diabetic amyotrophy E13.49 Other specified diabetes mellitus with other diabetic neurological complication E13.51 Other specified diabetes mellitus with diabetic peripheral angiopathy without gangrene E13.52 Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene E13.59 Other specified diabetes mellitus with other circulatory complications I Atherosclerosis of native arteries of right leg with ulceration of thigh I Atherosclerosis of native arteries of right leg with ulceration of calf I Atherosclerosis of native arteries of right leg with ulceration of ankle I Atherosclerosis of native arteries of right leg with ulceration of heel and midfoot I Atherosclerosis of native arteries of right leg with ulceration of other part of foot Atherosclerosis of native arteries of right leg with ulceration of other part of lower right leg I I Atherosclerosis of native arteries of right leg with ulceration of unspecified site I Atherosclerosis of native arteries of left leg with ulceration of thigh I Atherosclerosis of native arteries of left leg with ulceration of calf 4

5 I Atherosclerosis of native arteries of left leg with ulceration of ankle I Atherosclerosis of native arteries of left leg with ulceration of heel and midfoot I Atherosclerosis of native arteries of left leg with ulceration of other part of foot I Atherosclerosis of native arteries of left leg with ulceration of other part of lower left leg I Atherosclerosis of native arteries of left leg with ulceration of other part of lower left leg I70.25 Atherosclerosis of native arteries of other extremities with ulceration I thigh I calf I ankle I heel and midfoot I other part of foot I other part of lower leg I unspecified site I thigh I calf I ankle I heel and midfoot I other part of foot I other part of lower leg I unspecified site I70.35 Atherosclerosis of unspecified type of bypass graft(s) of other extremity with ulceration Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of I thigh I Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of calf Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of I ankle Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of I heel and midfoot Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of I other part of foot Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of I other part of lower leg Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of unspecified site I I Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of thigh I Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of calf I Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of ankle I Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of heel and midfoot 5

6 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of other I part of foot Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of other I part of lower leg Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of I unspecified site I70.45 Atherosclerosis of autologous vein bypass graft(s) of other extremity with ulceration I ulceration of thigh I ulceration of calf I ulceration of ankle I ulceration of heel and midfoot I ulceration of other part of foot I ulceration of other part of lower leg I ulceration of unspecified site I ulceration of thigh I ulceration of calf I ulceration of ankle I ulceration of heel and midfoot I ulceration of other part of foot I ulceration of other part of lower leg I ulceration of unspecified site Atherosclerosis of nonautologous biological bypass graft(s) of other extremity with I70.55 ulceration I Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of thigh I Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of calf I Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of ankle Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of heel I and midfoot Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of other I part of foot Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of other I part of lower leg Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of I unspecified site I Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of thigh I Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of calf I Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of ankle Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of heel I and midfoot I Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of other 6

7 part of foot Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of other I part of lower leg Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of I unspecified site I70.65 Atherosclerosis of nonbiological bypass graft(s) of other extremity with ulceration I Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of thigh I Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of calf I Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of ankle Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of heel I and midfoot Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of other I part of foot Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of other I part of lower leg Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of I unspecified site I Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of thigh I Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of calf I Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of ankle Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of heel and I midfoot Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of other I part of foot Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of other I part of lower leg Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of I unspecified site I70.75 Atherosclerosis of other type of bypass graft(s) of other extremity with ulceration I Varicose veins of unspecified lower extremity with ulcer of thigh I Varicose veins of unspecified lower extremity with ulcer of calf I Varicose veins of unspecified lower extremity with ulcer of ankle I Varicose veins of unspecified lower extremity with ulcer of heel and midfoot I Varicose veins of unspecified lower extremity with ulcer other part of foot I Varicose veins of unspecified lower extremity with ulcer other part of lower leg I Varicose veins of unspecified lower extremity with ulcer of unspecified site I Varicose veins of right lower extremity with ulcer of thigh I Varicose veins of right lower extremity with ulcer of calf I Varicose veins of right lower extremity with ulcer of ankle I Varicose veins of right lower extremity with ulcer of heel and midfoot I Varicose veins of right lower extremity with ulcer other part of foot I Varicose veins of right lower extremity with ulcer other part of lower leg I Varicose veins of right lower extremity with ulcer of unspecified site I Varicose veins of left lower extremity with ulcer of thigh I Varicose veins of left lower extremity with ulcer of calf I Varicose veins of left lower extremity with ulcer of ankle I Varicose veins of left lower extremity with ulcer of heel and midfoot I Varicose veins of left lower extremity with ulcer other part of foot I Varicose veins of left lower extremity with ulcer other part of lower leg I Varicose veins of left lower extremity with ulcer of unspecified site I87.2 Venous insufficiency (chronic) (peripheral) L89.93 Pressure ulcer of unspecified site, stage 3 7

8 L89.94 Pressure ulcer of unspecified site, stage 4 L89.95 Pressure ulcer of unspecified site, unstageable L Pressure ulcer of unspecified elbow, unstageable L Pressure ulcer of unspecified elbow, stage 3 L Pressure ulcer of unspecified elbow, stage 4 L Pressure ulcer of right elbow, unstageable L Pressure ulcer of right elbow, stage 3 L Pressure ulcer of right elbow, stage 4 L Pressure ulcer of left elbow, unstageable L Pressure ulcer of left elbow, stage 3 L Pressure ulcer of left elbow, stage 4 L Pressure ulcer of unspecified part of back, unstageable L Pressure ulcer of unspecified part of back, stage 3 L Pressure ulcer of unspecified part of back, stage 4 L Pressure ulcer of right upper back, unstageable L Pressure ulcer of right upper back, stage 3 L Pressure ulcer of right upper back, stage 4 L Pressure ulcer of left upper back, unstageable L Pressure ulcer of left upper back, stage 3 L Pressure ulcer of left upper back, stage 4 L Pressure ulcer of right lower back, unstageable L Pressure ulcer of right lower back, stage 3 L Pressure ulcer of right lower back, stage 4 L Pressure ulcer of left lower back, unstageable L Pressure ulcer of left lower back, stage 3 L Pressure ulcer of left lower back, stage 4 L Pressure ulcer of sacral region, unstageable L Pressure ulcer of sacral region, stage 3 L Pressure ulcer of sacral region, stage 4 L89.43 Pressure ulcer of contiguous site of back, buttock and hip, stage 3 L89.44 Pressure ulcer of contiguous site of back, buttock and hip, stage 4 L89.45 Pressure ulcer of contiguous site of back, buttock and hip, unstageable L Pressure ulcer of unspecified hip, unstageable L Pressure ulcer of unspecified hip, stage 3 L Pressure ulcer of unspecified hip, stage 4 L Pressure ulcer of right hip, unstageable L Pressure ulcer of right hip, stage 3 L Pressure ulcer of right hip, stage 4 L Pressure ulcer of left hip, unstageable L Pressure ulcer of left hip, stage 3 L Pressure ulcer of left hip, stage 4 L89.43 Pressure ulcer of contiguous site of back, buttock and hip, stage 3 L89.44 Pressure ulcer of contiguous site of back, buttock and hip, stage 4 L89.45 Pressure ulcer of contiguous site of back, buttock and hip, unstageable L Pressure ulcer of unspecified buttock, unstageable L Pressure ulcer of unspecified buttock, stage 3 L Pressure ulcer of unspecified buttock, stage 4 L Pressure ulcer of right buttock, unstageable L Pressure ulcer of right buttock, stage 3 L Pressure ulcer of right buttock, stage 4 L Pressure ulcer of left buttock, unstageable 8

9 L Pressure ulcer of left buttock, stage 3 L Pressure ulcer of left buttock, stage 4 L89.43 Pressure ulcer of contiguous site of back, buttock and hip, stage 3 L89.44 Pressure ulcer of contiguous site of back, buttock and hip, stage 4 L89.45 Pressure ulcer of contiguous site of back, buttock and hip, unstageable L Pressure ulcer of unspecified ankle, unstageable L Pressure ulcer of unspecified ankle, stage 3 L Pressure ulcer of unspecified ankle, stage 4 L Pressure ulcer of right ankle, unstageable L Pressure ulcer of right ankle, stage 3 L Pressure ulcer of right ankle, stage 4 L Pressure ulcer of left ankle, unstageable L Pressure ulcer of left ankle, stage 3 L Pressure ulcer of left ankle, stage 4 L Pressure ulcer of unspecified heel, unstageable L Pressure ulcer of unspecified heel, stage 3 L Pressure ulcer of unspecified heel, stage 4 L Pressure ulcer of right heel, unstageable L Pressure ulcer of right heel, stage 3 L Pressure ulcer of right heel, stage 4 L Pressure ulcer of left heel, unstageable L Pressure ulcer of left heel, stage 3 L Pressure ulcer of left heel, stage 4 L Pressure ulcer of head, unstageable L Pressure ulcer of head, stage 3 L Pressure ulcer of head, stage 4 L Pressure ulcer of other site, unstageable L Pressure ulcer of other site, stage 3 L Pressure ulcer of other site, stage 4 L89.93 Pressure ulcer of unspecified site, stage 3 L Non-pressure chronic ulcer of unspecified thigh with fat layer exposed L Non-pressure chronic ulcer of unspecified thigh with necrosis of muscle L Non-pressure chronic ulcer of unspecified thigh with necrosis of bone L Non-pressure chronic ulcer of right thigh with fat layer exposed L Non-pressure chronic ulcer of right thigh with necrosis of muscle L Non-pressure chronic ulcer of right thigh with necrosis of bone L Non-pressure chronic ulcer of left thigh with fat layer exposed L Non-pressure chronic ulcer of left thigh with necrosis of muscle L Non-pressure chronic ulcer of left thigh with necrosis of bone L Non-pressure chronic ulcer of unspecified calf with fat layer exposed L Non-pressure chronic ulcer of unspecified calf with necrosis of muscle L Non-pressure chronic ulcer of unspecified calf with necrosis of bone L Non-pressure chronic ulcer of right calf with fat layer exposed L Non-pressure chronic ulcer of right calf with necrosis of muscle L Non-pressure chronic ulcer of right calf with necrosis of bone L Non-pressure chronic ulcer of left calf with fat layer exposed L Non-pressure chronic ulcer of left calf with necrosis of muscle L Non-pressure chronic ulcer of left calf with necrosis of bone L Non-pressure chronic ulcer of unspecified ankle with fat layer exposed L Non-pressure chronic ulcer of unspecified ankle with necrosis of muscle L Non-pressure chronic ulcer of unspecified ankle with necrosis of bone 9

10 L Non-pressure chronic ulcer of right ankle with fat layer exposed L Non-pressure chronic ulcer of right ankle with necrosis of muscle L Non-pressure chronic ulcer of right ankle with necrosis of bone L Non-pressure chronic ulcer of left ankle with fat layer exposed L Non-pressure chronic ulcer of left ankle with necrosis of muscle L Non-pressure chronic ulcer of left ankle with necrosis of bone L Non-pressure chronic ulcer of unspecified heel and midfoot with fat layer exposed L Non-pressure chronic ulcer of unspecified heel and midfoot with necrosis of muscle L Non-pressure chronic ulcer of unspecified heel and midfoot with necrosis of bone L Non-pressure chronic ulcer of right heel and midfoot with fat layer exposed L Non-pressure chronic ulcer of right heel and midfoot with necrosis of muscle L Non-pressure chronic ulcer of right heel and midfoot with necrosis of bone L Non-pressure chronic ulcer of left heel and midfoot with fat layer exposed L Non-pressure chronic ulcer of left heel and midfoot with necrosis of muscle L Non-pressure chronic ulcer of left heel and midfoot with necrosis of bone L Non-pressure chronic ulcer of other part of unspecified foot with fat layer exposed L Non-pressure chronic ulcer of other part of unspecified foot with necrosis of muscle L Non-pressure chronic ulcer of other part of unspecified foot with necrosis of bone L Non-pressure chronic ulcer of other part of right foot with fat layer exposed L Non-pressure chronic ulcer of other part of right foot with necrosis of muscle L Non-pressure chronic ulcer of other part of right foot with necrosis of bone L Non-pressure chronic ulcer of other part of left foot with fat layer exposed L Non-pressure chronic ulcer of other part of left foot with necrosis of muscle L Non-pressure chronic ulcer of other part of left foot with necrosis of bone L Non-pressure chronic ulcer of other part of unspecified lower leg with fat layer exposed Non-pressure chronic ulcer of other part of unspecified lower leg with necrosis of L muscle L Non-pressure chronic ulcer of other part of unspecified lower leg with necrosis of bone L Non-pressure chronic ulcer of other part of right lower leg with fat layer exposed L Non-pressure chronic ulcer of other part of right lower leg with necrosis of muscle L Non-pressure chronic ulcer of other part of right lower leg with necrosis of bone L Non-pressure chronic ulcer of other part of left lower leg with fat layer exposed L Non-pressure chronic ulcer of other part of left lower leg with necrosis of muscle L Non-pressure chronic ulcer of other part of left lower leg with necrosis of bone Non-pressure chronic ulcer of unspecified part of unspecified lower leg with fat layer L exposed Non-pressure chronic ulcer of unspecified part of unspecified lower leg with necrosis of L muscle Non-pressure chronic ulcer of unspecified part of unspecified lower leg with necrosis of L bone L Non-pressure chronic ulcer of unspecified part of right lower leg with fat layer exposed Non-pressure chronic ulcer of unspecified part of right lower leg with necrosis of muscle L L Non-pressure chronic ulcer of unspecified part of right lower leg with necrosis of bone L Non-pressure chronic ulcer of unspecified part of left lower leg with fat layer exposed L Non-pressure chronic ulcer of unspecified part of left lower leg with necrosis of muscle L Non-pressure chronic ulcer of unspecified part of left lower leg with necrosis of bone L Pressure ulcer of unspecified elbow, stage 3 L Pressure ulcer of unspecified elbow, stage 4 L Pressure ulcer of unspecified elbow, unstageable L Non-pressure chronic ulcer of buttock with fat layer exposed 10

11 L Non-pressure chronic ulcer of buttock with necrosis of muscle L Non-pressure chronic ulcer of buttock with necrosis of bone L Non-pressure chronic ulcer of back with fat layer exposed L Non-pressure chronic ulcer of back with necrosis of muscle L Non-pressure chronic ulcer of back with necrosis of bone L Non-pressure chronic ulcer of skin of other sites with fat layer exposed L Non-pressure chronic ulcer of skin of other sites with necrosis of muscle L Non-pressure chronic ulcer of skin of other sites with necrosis of bone L Non-pressure chronic ulcer of skin of other sites with unspecified severity Description Electrical stimulation refers to the application of electrical current through electrodes placed directly on the skin in close proximity to the wound. Electromagnetic therapy involves the application of electromagnetic fields rather than direct electrical current. Both are proposed as treatments for chronic wounds. The normal wound healing process involves inflammatory, proliferative, and remodeling phases. When the healing process fails to progress properly and the wound persists for longer than 1 month, it may be described as a chronic wound. The types of chronic wounds most frequently addressed in studies of electrical stimulation for wound healing are 1) pressure ulcers, 2) venous ulcers, 3) arterial ulcers, and 4) diabetic ulcers. Conventional or standard therapy for chronic wounds involves local wound care, as well as systemic measures including debridement of necrotic tissues, wound cleansing, and dressing that promotes a moist wound environment, antibiotics to control infection, and optimizing nutritional supplementation. Non-weight bearing is another important component of wound management. No electrical stimulation or electromagnetic therapy devices have received approval from the U.S. Food and Drug Administration (FDA), specifically for the treatment of wound healing. A number of devices have been cleared for marketing for other indications. Use of these devices for wound healing is an off-label indication. Summary There is insufficient evidence from well-designed randomized controlled trials (RCTs) that electrostimulation or electromagnetic stimulation improves health outcomes for wound care patients beyond that provided by standard treatment. Some small RCTs on electrostimulation have reported improvements in some intermediate outcomes, such as decrease in wound size and/or the velocity of wound healing. However, these studies have not demonstrated consistent improvements on the more important clinical outcomes of complete healing and the time to complete healing. For electromagnetic therapy, there is a lack of high-quality RCTs. Therefore, these treatments are considered investigational for the treatment of wounds. Policy History Date Action 7/2014 Updated Coding section with ICD10 procedure and diagnosis codes, effective 10/ /2014 BCBSA National medical policy review. New investigational indications described. Effective 3/1/2014. Coding information clarified. 11/2011- Medical policy ICD 10 remediation: Formatting, editing and coding updates. 4/ /2011 Reviewed - Medical Policy Group - Plastic Surgery and Dermatology. 12/2010 Reviewed - Medical Policy Group - Plastic Surgery and Dermatology. 12/2009 Reviewed - Medical Policy Group - Plastic Surgery and Dermatology. 11

12 9/2009 BCBSA National medical policy review. 6/2009 BCBSA National medical policy review. 12/2008 Reviewed - Medical Policy Group - Plastic Surgery and Dermatology. 7/2008 BCBSA National medical policy review. Changes to policy statements. 3/2008 Reviewed - Medical Policy Group - Allergy and ENT/Otolaryngology. 3/2007 BCBSA National medical policy review. 3/2007 Reviewed - Medical Policy Group - Allergy and ENT/Otolaryngology. Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines References 1. Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Electrical stimulation or electromagnetic therapy as adjunctive treatments for chronic skin wounds. TEC Assessments 2005; Volume 20, Tab Medicare Technology Assessments for Electrostimulation for Wounds (CAG-00068N). Available online at: AAAACAAAAA%3d%3d&. Last accessed September, Game FL, Hinchliffe RJ, Apelqvist J et al. A systematic review of interventions to enhance the healing of chronic ulcers of the foot in diabetes. Diabetes Metab Res Rev 2012; 28 Suppl 1: Aziz Z, Flemming K. Electromagnetic therapy for treating pressure ulcers. Cochrane Database Syst Rev 2012; 12:CD Aziz Z, Cullum N, Flemming K. Electromagnetic therapy for treating venous leg ulcers. Cochrane Database Syst Rev 2013; 2:CD Adunsky A, Ohry A, Ddct G. Decubitus direct current treatment (DDCT) of pressure ulcers: results of a randomized double-blinded placebo controlled study. Arch Gerontol Geriatr 2005; 41(3): Houghton PE, Campbell KE, Fraser CH et al. Electrical stimulation therapy increases rate of healing of pressure ulcers in community-dwelling people with spinal cord injury. Arch Phys Med Rehabil 2010; 91(5): Franek A, Kostur R, Polak A et al. Using high-voltage electrical stimulation in the treatment of recalcitrant pressure ulcers: results of a randomized, controlled clinical study. Ostomy Wound Manage 2012; 58(3): Gupta A, Taly AB, Srivastava A et al. Efficacy of pulsed electromagnetic field therapy in healing of pressure ulcers: a randomized control trial. Neurol India 2009; 57(5): Association for the Advancement of Wound Care (AAWC). Association for the Advancement of Wound Care guideline of pressure ulcer guidelines. Available online at: Last accessed September, CMS Manual System. Pub Medicare National Coverage Determinations Available online at: Last accessed September,

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