This policy version was replaced May 30, 2022. To find the newest version, go to https://www.bluecrossmn.com/providers/medical-policy-and-utilization-management, read and accept the Blue Cross Medical Policy Statement, then select “Blue Cross and Blue Shield of Minnesota Medical Policies.” This will bring up the Medical Policy search screen. Enter the policy number without the version number (last 3 digits).
Electrical stimulation has been proposed as a treatment for osteoarthritis and rheumatoid arthritis when functional status and pain are unresponsive to other standard therapies. Electrical stimulation is provided by devices that noninvasively deliver 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 and held in place with a lightweight, flexible wrap.
Electrical stimulators, including but not limited to the BioniCare® Knee System (formerly the Bio-1000 stimulator) and the J-Stim 1000™ have received 510(k) marketing clearance from the U.S. Food and Drug Administration (FDA) for use as an adjunctive therapy in reducing the level of pain and symptoms associated with osteoarthritis of the knee. The Bio-1000™ and J-Stim 1000™ have also received FDA marketing clearance for use as adjunctive therapy in reducing the level of pain and stiffness associated with rheumatoid arthritis (RA) of the hand.
The OrthoCor™ Active Knee System, which uses pulsed electromagnetic field energy, received marketing clearance from the FDA and is classified as a shortwave diathermy device for use other than applying therapeutic deep heat. 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 use of electrical/electromagnetic stimulation for the treatment of osteoarthritis or rheumatoid arthritis is considered EXPERIMENTAL/INVESTIGATIVE due to lack of clinical evidence demonstrating an impact on improved health outcomes.
No additional statements.
Blue Cross and Blue Shield of Minnesota medical policies apply generally to all Blue Cross and Blue Plus plans and products. Benefit plans vary in coverage and some plans may not provide coverage for certain services addressed in the medical policies. When determining coverage, reference the member’s specific benefit plan, including exclusions and limitations.
Medicaid products may provide different coverage for certain services, which may be addressed in different policies. For Minnesota Health Care Program (MHCP) policies, please consult the MHCP Provider Manual website.
Medicare products may provide different coverage for certain services, which may be addressed in different policies. For Medicare National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and/or Local Coverage Articles, please consult CMS, National Government Services, or CGS websites.
Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met.
Blue Cross and Blue Shield of Minnesota reserves the right to revise, update and/or add to its medical policies at any time without notice. Codes listed on this policy are included for informational purposes only and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement.
These guidelines are the proprietary information of Blue Cross and Blue Shield of Minnesota. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Acknowledgements:
CPT® codes copyright American Medical Association® 2022. All rights reserved.
CDT codes copyright American Dental Association® 2022. All rights reserved.